Novel Delivery Systems for Nicotine Replacement Therapy as an Aid to Smoking Cessation and for Harm Reduction: Rationale
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LEADING ARTICLE
Novel Delivery Systems for Nicotine Replacement Therapy as an Aid to Smoking Cessation and for Harm Reduction: Rationale, and Evidence for Advantages over Existing Systems Lion Shahab • Leonie S. Brose • Robert West
Published online: 11 October 2013 Ó Springer International Publishing Switzerland 2013
Abstract Nicotine replacement therapy (NRT) has been used in the treatment of tobacco dependence for over three decades. Whilst the choice of NRT was limited early on, in the last ten years there has been substantial increase in the number of nicotine delivery devices that have become available. This article briefly summarises existing forms of NRT, evidence of their efficacy and use, and reviews the rationale for the development of novel products delivering nicotine via buccal, transdermal or pulmonary routes (including nicotine mouth spray, nicotine films, advanced nicotine inhalers and electronic cigarettes). It presents available evidence on the efficacy, tolerability and abuse potential of these products, with a focus on their advantages as well as disadvantages compared with established forms of NRT for use as an aid to both smoking cessation as well as harm reduction.
1 Introduction Whilst tobacco consumption in the developed world is declining, smoking remains a major public health concern given continued high consumption in developing countries and the resultant world-wide death toll associating with it. Smoking is the biggest avoidable cause of premature death, predicted to kill over eight million lives annually by 2030 if current trends continue [1]. These figures highlight the L. Shahab (&) R. West Department of Epidemiology and Public Health, University College London, 1-19 Torrington Place, London WC1E 6BT, UK e-mail: [email protected] L. S. Brose Institute of Psychiatry, King’s College London, London, UK
on-going need to support tobacco users to reduce the burden of the tobacco epidemic. Although nicotine, a major alkaloid found in tobacco, is the primary cause of tobacco dependence, pure nicotine itself is thought for the vast majority of smokers to be safe at the levels delivered by cigarettes or other nicotine delivery devices [2, 3]. Nicotine inhaled in cigarette smoke is rapidly absorbed through the alveoli in the lung into the pulmonary alveolar capillary, taking less than 20 s to reach the brain [4], where it has pervasive effects on neurochemistry [5]. Tobacco dependence is thought to be mediated by the dopaminergic mesolimbic pathway activated by the actions of nicotine in the ventral tegmentum [6, 7]. Indeed, it has been shown that smokers smoke mainly to obtain nicotine [8], leading tobacco use to be described as a form of nicotine self-administration [9]. Concurrent with these positive reinforcing effects of nicotine, chronic exposure leads to changes in the neurophysiological substrate which cause unpleasant withdrawal symptoms during abstinence and an ‘acquired drive’ to smoke modulated by CNS nicotine concentrations [7, 10]. In short, nicotine drives motivation to
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