Managing cravings

Cigarette cravings can make or break a smoker’s chance of quitting

succesfully.1 The goal of this activity is to improve pharmacists’
knowledge on cravings and strategies to help quitters manage them.

This learning activity is sponsored as a service to the

medical profession by Johnson & Johnson Sdn. Bhd.

START MODULE
Topics at a glance
• About smoking cessation
• Nicotine dependence & craving
• Management strategies
• Summary

1
About smoking cessation Cancers Chronic Diseases
Harms of smoking Stroke
Head or Neck Blindness
• When burned, cigarettes contain over 7,000 Gum infection
chemicals – at least 69 are carcinogenic and Lung Aortic rupture
many are poisonous2 Leukaemia Heart disease
• The World Health Organization (WHO) estimated Stomach
Pneumonia
that almost 6 million people die each year due Pancreas
to direct tobacco use and second-hand smoke3 Kidney Chronic lung
• Globally, smoking is estimated to cause about disease & asthma
Colon
71% of lung cancer, 42% chronic lung disease Bladder Hardening of
and nearly 10% of heart disease3 the arteries
Cervix
• In Malaysia, about a quarter of the population Reduced fertility
smoke tobacco – 43.9% of men and 1% of Hip fracture
women. Tobacco use accounts for 35% of
in-hospital deaths, mainly due to cancer, heart
disease and stroke4

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About smoking cessation
Benefits of quitting smoking4
20 minutes Blood pressure and heart rate return to normal. Body temperature normalizes
8 hours Carbon monoxide level in the body drops to normal. Oxygen level drops to normal
24 hours Risk of heart attack decreases. The lungs begin to clear out toxins and mucous
48 hours Taste and smell sensations return to normal
Breathing becomes easier as bronchial tubes relax; lung function improves. Energy
72 hours
level increases
3 months Blood circulation improves. Lung function increases
By 9 months Less coughing, shortness of breath, sinus congestion and fatigue
By 1 year Risk of heart disease drops by 50%
Risk of stroke and heart disease reduce to that of a non-smoker. Risk of lung cancer
5–10 years
drops to about half of that of a non-smoker

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Nicotine dependence and craving
Nicotine dependence and addiction7
• Tobacco smoking is a very effective way of delivering The nicotine addiction cycle7
nicotine into the body
30
• Upon inhalation, nicotine enters the blood circulation
rapidly via the lungs and moves into the brain within

Plasma nicotine (ng/mL)

Pleasure or
seconds arousal

• This creates a strongly felt “rush” and reinforces the

effects of nicotine. Besides the rapid rush of nicotine to
Neutral zone
the brain, cigarettes contain additives and engineered Withdrawal
features to enhance its addictiveness 0
│ │ │
symptoms

8 am 6 pm 4 am
• Repeated smoking throughout the day produces Time (hr)
significant peaks and troughs in blood nicotine levels
(refer to Figure), causing alternating improved mood or mental functioning and subsequent
withdrawal symptoms and cravings in the absence of nicotine. Each successive cigarette produces
greater level of nicotine tolerance and withdrawal symptoms become more pronounced

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Nicotine dependence and craving
Nicotine cravings8
Behavioural aspects of nicotine
• Defined as “feelings of need for a cigarette” dependence and craving7
• It is a common symptom that smokers who are Cue-induced
quitting are most concerned of and would like to cravings triggered
ameliorate through treatment by smoking cues
Withdrawal and environment
symptoms
• There are two types of cravings, ie, and
− Background craving: Craving that rises slowly cravings
soon after abstinence. Smokers experience this as a
Nicotine Cigarette
relatively steady, tonic state over the course of days or level drops smoking
hours; fluctuating slowly
− Cue-induced craving: Episodes of intense craving
triggered by exposure to situational stimuli that are
Improved
associated with smoking mood, mental Nicotine
■ Smoking cues, eg, food, alcohol, coffee or physical spike
■ Smoking environment, eg, restaurants, friends who functioning
smoke, stress-related (ie, work, family, money)

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Management strategies
Nonpharmacotherapy interventions
• The 5 A’s framework is designed to allow healthcare • To motivate smokers who are not willing
professionals incorporate smoking cessation counselling or ready to quit, the 5 R’s may be used to
into their practice9 reinforce the importance of quitting9
Ask about tobacco use Help smokers to identify reasons
- Identify and document tobacco use for every patient at every visit Relevance for quitting that are personally
relevant
Advise to quit
- Urge smoker to quit in a clear, strong and personalized manner Advise smokers on the harmful
Risks effects of continued smoking
Assess willingness to quit
Ask smokers to identify the
- Assess and identify willingness and readiness to quit and barriers to quitting Rewards benefits of quitting

Assist in quit attempt Explore the potential barriers

- Counselling (identify potential barriers to quitting)
Roadblocks to quitting that smokers may
- Motivational support (family, coworkers, self-help groups) encounter
- Pharmacotherapy (if indicated)
Reinforce the 5 R's at each
Arrange for follow ups Repeat clinical contact with the
- Close and regular follow ups, as early as within the first week after the quit date unmotivated smoker

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Management strategies
Pharmacotherapy interventions
• Expert committee of the Malaysia Clinical Practice Guideline on Treatment of Tobacco Use and
Dependence recommends pharmacotherapy for all smokers attempting to quit with Fagerstrom’s scores ≥4.
Pharmacotherapy is also recommended for those with Fagerstrom’s score <4 and smoking
>10 cigarettes/day; a lowered dose may be used in those who smokes <10 cigarettes/day9
• The table below showcases the available pharmacotherapy for smoking cessation in Malaysia10
Type of pharmacotherapy Comments

Nicotine replacement • The goal of NRT is to relieve nicotine cravings and withdrawal symptoms
therapy (NRT)9,11 • Available as slow-release patches and more rapid-acting forms (ie, chewing gums and lozenges) which deliver
nicotine to the brain more quickly than skin patches but more slowly than smoking cigarettes
• All forms of NRT increase the chance of successful quitting by 50–70%
• Heavy smokers should be encouraged to use higher dosages of NRT or combining two types of NRT (skin patch +
rapid acting form) to manage breakthrough cravings

Varenicline11 • A selective partial agonist of the nicotinic receptor that helps to reduce cravings and withdrawal symptoms while
blocking the binding of smoked nicotine
• Increases the chance of successful quitting by two- to three-fold compared with no pharmacologic assistance

● NRT gums or lozenges are useful as “rescue medications” – these can be used to rapidly reduce craving in cue-induced craving
episodes that threaten abstinence8
● Other pharmacotherapy agents (NRT patch, varenicline or bupropion) have no effect on cue-induced cravings; these are effective on
background cravings only8

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Management strategies
The role of counselling in smoking cessation
• Counselling is an effective intervention in smoking cessation. In fact, individual counselling has been
shown to result in higher abstinence rates compared with group/phone counselling and self-help9

Practical counselling points for pharmacists12

√ Insist on total abstinence
√ Highlight that even one single puff of the cigarette after the quit date can increase the chance of total relapse
√ Identify what went wrong in the smoker’s previous attempt to quit
√ Discuss on how smokers can avoid the same mistakes and increase their chances of successful quitting
√ Anticipate and solve problems caused by nicotine cravings and withdrawal symptoms
√ Demonstrate belief in the smoker’s ability to quit
√ Discuss on the success of supportive therapies available for smoking cessation
√ Ask smokers about their fears and attitudes on quitting
√ Provide help and encouragement when smokers encounter difficulties
√ Reinforce the reasons of quit smoking
√ Celebrate the successes that they have achieved

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Management strategies
Tips on coping with withdrawal symptoms and nicotine cravings13
• Withdrawal symptoms are at their strongest in the first few days (sometimes even up to the first few weeks)
of quitting, making it most difficult to cope for smokers
• There will also be times after quitting and when withdrawal symptoms have passed, that smokers will have
nicotine cravings and be tempted to lit a cigarette. Here are some tips that pharmacists can offer to help
smokers overcome them

Withdrawal symptoms What to do Triggers Coping strategies

Irritability Go for a walk. Take deep breaths Being in the company of Temporarily stay away from social situations where there will be smokers.
smokers Choose nonsmoking section in restaurants
Depression Speak to a friend or a family member. Seek help
Alcohol Temporarily abstain from alcohol
from a doctor if the feeling persists
Headaches Use mild analgesics. Drink plenty of water. Relax Coffee Avoid coffee or other caffeinated drinks. Choose juices or water instead
and rest
Appetite changes Follow a well-balanced diet. Choose healthy, low- First thing in the Change the routine — go for a walk or take a shower
fat snacks such as fruits morning after waking up

Constipation Ensure sufficient intake of water, fruits and After meals Change the routine — start clearing up the table and washing up the dishes,
vegetables brush teeth, take a walk or call a friend

Insomnia Avoid caffeinated beverages (ie, coffee, tea) at Random urges to The urge only last for a few minutes. Do activities for distraction like solve a
night. Try relaxation techniques before bed smoke puzzle, eat a healthy snack, watch television or go for a walk

Difficulty concentrating Take regular short breaks every few hours Stress Identify the sources of stress and try to avoid them. Use relaxation techiques like
yoga and deep breathing

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Management strategies
Importance of follow ups during smoking cessation
• Regular follow ups of smokers in their quit Suggested follow up schedules for smoking
journey increase the chance of long-term cessation9
abstinence6
1st follow up Within the 1st week after the quit date
• Actions to take during follow ups :11

− Ask about medication use and problems

− Discuss about triggers and reinforce ways to 2nd — 4th
Weekly within the 1st month of quitting
manage the triggers follow up
− Congratulate if the individual has been
successful in keeping away from smoking 5th — 8th Every 2 weeks for the 2nd and 3rd month of
− Underline the health benefits that the smoker follow up quitting
has begun to reap due to smoking cessation
− Identify problems already encountered and Subsequent
Monthly, up to 6 months
anticipate challenges in the immediate future follow ups
− If the smoker has had a lapse, reassure him/her
that it can be a learning experience

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Management strategies
Dealing with a relapse
• Relapse, ie, the failure to maintain behaviour change over
time, is an inevitable part of the quitting process – most Common factors of relapses13
smokers experience relapse several times before achieving
long-term success13 • Alcohol use
• Depression
• The risk of relapses continue to be high even after withdrawal • Negative self-talk
symptoms have passed, largely due to exposure to
• Other smokers in household
temptations, social situations and other triggers of smoking13
• Prolonged withdrawal symptoms
• It is important to reassure the smokers that relapses are • Exposure to high-risk situations, ie, social
learning opportunities, and not a sign of failure13 situations, arguments and other sources of
stress
• If a relapse occurs, encourage the smoker to repeat quit
• Dietary restriction
attempts. Help them to identify tempting situations and
• Lack of cessation support
develop specific plans to overcome them. Recommend
• Problems with pharmacotherapy
relaxation techniques and stress management skills13
• Long-term smoking cessation pharmacotherapy should be
considered as a strategy to reduce the likelihood of a relapse9

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Summary

• When burned, cigarettes contained many harmful and poisonous substances that can lead to chronic diseases and
cancers. On the other hand, smoking cessation is associated with many short- and long-term health benefits
• Tobacco smoking is an effective way of delivering nicotine to the body. Repeated smoking produces significant peaks and
troughs in plasma nicotine level, causing alternating improved mood or mental functioning and subsequent withdrawal
symptoms and cravings
• Nicotine craving is a symptom most smokers who are quitting are most concerned about and would like to ameliorate
through treatment. There are two types of cravings, ie, background and cue-induced cravings
• A holistic approach to help smokers quit successfully entails nonpharmacologic interventions and pharmacotherapy
− Pharmacists can use the 5 A’s framework to incorporate smoking cessation counselling into their practice, while the 5 R’s strategy
may be used to reinforce the importance of quitting
− Pharmacotherapy is indicated for smokers who are attempting to quit; it is also an important strategy to reduce the likelihood of
relapse
− NRT gums or lozenges are useful as “rescue medications” and can be used to rapidly reduce craving in cue-induced craving
episodes that threaten abstinence. Other pharmacotherapy agents (NRT patch, varenicline or bupropion) are effective on background
cravings only
• Counselling is effective and should be actively incorporated into smoking cessation efforts. Counselling should include
strategies on how to deal with withdrawal symptoms and smoking triggers
• Regular follow ups help smokers increase their chance of long-term abstinence
• Relapse is an inevitable part of the quitting process; it is important to reassure the smokers that relapses are learning
opportunities, and not a sign of failure. If a relapse occurs, encourage the smoker to repeat quit attempts

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References
1. NHS Choices. Stop smoking: Coping with cravings. Available at: http://www.nhs.uk/Livewell/smoking/Pages/Copingwithcravings.aspx. Accessed 12 December 2016.
2. American Lung Association. What’s in a cigarette? Available at: http://www.lung.org/stop-smoking/smoking-facts/whats-in-a-cigarette.html. Accessed 12 December 2016.
3. World Health Organization. Global status report on noncommunicable diseases 2010. Available at: http://www.who.int/nmh/publications/ncd_report_full_en.pdf. Accessed 12 December 2016.
4. Global Adult Tobacco Survey Malaysia 2011. Available at: http://www.who.int/tobacco/surveillance/survey/gats/malaysia_country_report_2011.pdf. Accessed 12 December 2016.
5. Centers for Disease Control and Prevention. Health effects of cigarette smoking. Available at: https://www.cdc.gov/tobacco/data_statistics/fact_sheets/health_effects/effects_cig_smoking/.
Accessed 12 December 2016.
6. Health Promotion Board. Clinical Practice Guidelines: Treating tobacco use and dependence. Available at: http://www.hpb.gov.sg/HOPPortal/content/conn/HOPUCM/path/Contribution%20
Folders/uploadedFiles/HPB_Online/Publications/CPG_Treating_Tobacco_Use_and_Dependence_Main.pdf. Accessed 12 December 2016.
7. Benowitz NL. N Engl J Med 2010;362(24):2295–2303.
8. Ferguson SG, Shiffman S. J Subst Abuse Treat 2009;36(3):235–243.
9. Ministry of Health Malaysia. Clinical Practice Guidelines on Treatment of Tobacco Use and Dependence 2003. Available at: http://www.acadmed.org.my/view_file.cfm?fileid=282. Accessed 12
December 2016.
10. MIMS.com Malaysia. Smoking cessation. Available at: http://mims.com/malaysia/drug/search?q=Smoking%20cessation. Accessed 12 December 2016.
11. Larzelere MM, Wiilliams DE. Am Fam Physician 2012;85(6):591–598.
12. Tobacco Use and Dependence Guideline Panel. Treating Tobacco Use and Dependence: 2008 Update. Chapter 6 – Evidence and Recoomendations. Rockville (MD): US Department of Health and
Human Services; 2008 May 6, Evidence and Recommendations. Available from: https://www.ncbi.nlm.nih.gov/books/NBK63943/. Accessed 12 December 2016
13. Physicians for a Smoke-free Canada. Smoking Cessation Guidelines. Available at: http://www.smoke-free.ca/pdf_1/smoking_guide_en.pdf. Accessed 12 December 2016.

Editorial development by MIMS Medica. The opinions expressed in this publication are not necessarily those of the editor, publisher or sponsor. Any liability or obligation for loss or damage
howsoever arising is hereby disclaimed. ©2017 MIMS Medica. All rights reserved. No part of this publication may be reproduced by any process in any language without the written
permission of the publisher.
Enquiries: MIMS Medica Sdn Bhd (891450-U), 2nd Floor, West Wing, Quattro West, No. 4, Lorong Persiaran Barat, 46200 Petaling Jaya, Selangor, Malaysia.
Tel: (603) 7623 8000 Fax: (603) 7623 8188 Email: enquiry.my@mims.com Web site: www.mims.com MY-JJ-005

13
 This course is sponsored as a service
to the medical profession by Johnson & Johnson

FOR HEALTHCARE PROFESSIONALS ONLY.

The opinions expressed in this publication are not necessarily those of the editor, publisher or
sponsor. Any liability or obligation for loss or damage howsoever arising is hereby disclaimed. A
qualified healthcare professional should be consulted before using any therapeutic product discussed.
Readers should verify all information and data before treating patients or employing any therapies described
in this educational activity.

Johnson & Johnson Sdn. Bhd. (Co. No. 3718-D)

Level 8, The Pinnacle, Persiaran Lagoon, Bandar Sunway 14
46150 Petaling Jaya, Selangor.
 Smokers experience
Dual support to manage dual cravings3,4
two types of cravings,
ie, Background
For managing background For managing cue-induced
cravings. Relieves withdrawal cravings, eg, situational stimuli.

and Cue-induced
symptoms throughout the day. Actively relieves cravings within
15 minutes.

cravings1
Dual Support Dosage Guide
“Cravings are the most
important withdrawal Invisipatch Icymint Oral Gum
symptom to address Start
Star with 15 mg patch and
in smoking cessation. <15 CHEW
CHE a 2 mg gum when
cigarettes there
ther is an urge to smoke.

Cravings control /day Use no more than 12

pieces/day.
piec Taper down
is one of the most Taper down patch as
per guidance
Taper down until
not required
patch as per guidance.

important predictor of
successful quitting”2 Start
Star with 25 mg patch and
CHEW
CHE a 2 mg gum when
>15 there
ther is an urge to smoke.
cigarettes Use no more than 12
/day
pieces/day.
piec Taper down
Taper down patch as Taper down until patch as per guidance.
per guidance not required

References: 1. NHS Choices. Stop smoking: Coping with cravings. Available at: http://www.nhs.uk/Livewell/smoking/Pages/Copingwithcravings.aspx. Accessed 12 December 2016. 2. Ferguson SG, Shiffman S. J Subst Abuse Treat 2009;36(3):235–343. 3. Nicorette®
Gum Package Insert for Malaysia. 4. Nicorette® Invisi Patch Package Insert for Malaysia.

Johnson & Johnson Sdn. Bhd. (Co. No. 3718-D)

Level 8, The Pinnacle, Persiaran Lagoon, Bandar Sunway 15
46150 Petaling Jaya, Selangor.
Effect of NRT in
200
180
187
managing cravings

Total withdrawal
160
140
■ Combination NRT is 142
128.3
120
more effective than 100
monotherapy (patch or 80 101.1 99.2*+
gum) or “cold turkey” 60
40
in managing nicotine 20
cravings and withdrawal 0
Smoking Combination Patch Gum Placebo
symptoms1
Adapted from Fagerström KO et al. 19931
*Significantly superior to both single patch and single gum treatments (p<0.001) in preventing withdrawal symptoms
+
Significantly superior to double placebo (p<0.001) in preventing withdrawal symptoms

“Combination NRT is as effective as varenicline, and more effective than a single type of NRT for smoking cessation”
– Cahill K, et al. Cochrane Database Syst Rev 20132

References: 1. Fagerström KO, et al. Psychopharmacology (Berl) 1993;111(3):271–277. 2. Cahill K, et al. Cochrane Database Syst Rev 2013;(5):CD009329.

Johnson & Johnson Sdn. Bhd. (Co. No. 3718-D)

Level 8, The Pinnacle, Persiaran Lagoon, Bandar Sunway 16
46150 Petaling Jaya, Selangor.
Combination NRT provided Significantly higher cessation rates vs.
monotherapy at 12 and 24 weeks1
higher cessation rates
compared with monotherapy Combination (patch + gum) (n=149) Patch (n=150)

■ Combination NRT was significantly 40 p=0.027 p=0.010 p=0.191

superior to monotherapy in 35

% Abstinent
30
managing nicotine withdrawal 25
symptoms 20
15
■ Combination NRT was effective in 10
managing breakthrough cravings by 5
providing rapid relief 0
12 weeks 24 weeks 52 weeks
Weeks after start of treatment

Reference: 1. Kornitzer M, et al. Prev Med 1995;24(1):41–47.

Johnson & Johnson Sdn. Bhd. (Co. No. 3718-D)

Level 8, The Pinnacle, Persiaran Lagoon, Bandar Sunway 17
46150 Petaling Jaya, Selangor.
Abbreviated prescribing information
NAME OF THE PRODUCT: Nicorette® Icy Mint 2mg and 4mg gum containing 2mg and 4mg of nicotine (as resinate) respectively in a chewing gum base; Nicorette Invisi Transdermal Patch
10mg/16Hr, 15mg/16Hr and 25mg/16Hr. PHARMACEUTICAL FORM: A square chewable tablet (Icymint gum) and a semi-transparent patch (Invisipatch). INDICATION: Smoking cessation.
Nicorette is intended to help smokers who want to give up smoking but experience difficulty in doing so because of their nicotine dependence. As an aid to reduce smoking [Nicotine Assisted
Reduction to Stop (NARS)] DOSAGE AND ROUTE OF ADMINISTRATION: Adults: The initial dosage should be individualized on the basis of the smoker’s nicotine dependence. Oral Gum:
The Nicorette® chewing gum 4mg is recommended for smokers who are highly dependent (for example smoking 20 cigarettes or more per day or smoking the first cigarette in the morning 30
minutes or less after waking up). Other smokers should begin treatment with the 2mg dosage strength. The Nicorette® chewing gum should be used when cigarettes normally would have been
smoked or if cravings emerge. Sufficient Nicorette® chewing gum should be used each day. In order to maximize the chances of success it is important not to underdose. Dosing regime: 8 to
12 Nicorette® chewing gum per day, for at least 3 months. Do not exceed 24 gums per day. Smokers should stop smoking completely during the course of treatment with Nicorette® chewing
gum. Gradual tapering from the Nicorette® chewing gum should then be initiated. Treatment should be stopped when the dose is reduced to 1 to 2 Nicorette® chewing gum per day. Transdermal
Patch: The patch should be applied to an intact area of the skin upon waking up in the morning and removed at bedtime. Heavy smokers (those smoking 15 or more cigarettes in a 24-hour
period) are recommended to start at Step 1 with the 25mg/16 hours patch and use one patch daily for 8 weeks. Gradual weaning from the patch should then be initiated. One 15mg/16 hours
patch should be used daily for 2 weeks followed by one 10mg/16 hours patch daily for 2 weeks. Light smokers (those smoking less than 15 cigarettes in a 24-hour period) are recommended to
start at Step 2 (15mg/16 hours patch) for 8 weeks and decrease the dose to Step 3 (10mg/16 hours patch) for the final 4 weeks. Combination therapy: Highly dependent smokers, smokers who
experience “breakthrough” cravings or those who have failed with single NRT treatment, can use a flexible smoking cessation format, in combination with the patch for fast relief of cravings.
Children and adolescents: Nicorette® chewing gum and transdermal patch should not be administered to a person under 18 years of age without recommendation from healthcare professional.
CONTRAINDICATION: Hypersensitivity to nicotine or any excipient in the chewing gum or patch. WARNING AND PRECAUTIONS: The chewing gum may adhere to, and in rare cases damage,
dentures and dental bridges. Nicorette® patch should be removed prior to undergoing any Magnetic Resonance Imaging (MRI) procedures to prevent the risk of burns. Nicorette gum and patch
should only be used after consulting a physician by particular cardiovascular patient groups: those who have experienced a serious cardiovascular event, or hospitalization for a cardiovascular
complaint, in the previous 4 weeks (e.g. stroke, myocardial infarction, unstable angina, cardiac arrhythmia, coronary artery bypass graft and angioplasty) or where they suffer with uncontrolled
hypertension. Nicorette gum and patch should be used with caution in patients with severe/moderate hepatic impairment, severe renal impairment, active duodenal and gastric ulcers.
PREGNANCY AND LACTATION: Pregnancy • Nicorette chewing gum and patch should not be used by pregnant patients other than where there is a high level of nicotine dependence and on
doctor's advice. Lactation • Nicorette® chewing gum and transdermal patch should be avoided when breastfeeding. SIDE EFFECTS: Nicorette chewing gum and transdermal patch may cause
undesirable effects similar to those that appear when nicotine is administered by other routes. Most of the undesirable effects reported by the subjects occur during the early phase of treatment
and are mainly dose-dependent. SYMPTOMS AND TREATMENT OF OVERDOSE: The symptoms of overdosage are the same as the symptoms of acute nicotine poisoning, such as nausea,
increased salivation, abdominal pain, diarrhea, sweating, headache, dizziness, disturbed hearing and prostration. At high doses, these symptoms may be accompanied by low blood pressure,
weak and irregular pulse, breathing difficulties, exhaustion, circulatory collapse and general convulsions. Treatment for overdosage: All administration of nicotine is stopped immediately and the
patient should be treated for the symptoms. Charcoal reduces the absorption of nicotine in the gastrointestinal canal.
Please refer to the full prescribing information before prescribing.

Johnson & Johnson Sdn. Bhd. (Co. No. 3718-D)

Level 8, The Pinnacle, Persiaran Lagoon, Bandar Sunway 18
46150 Petaling Jaya, Selangor.
 Managing cravings

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