As mentioned earlier, the nicotine in cigarettes leads to actual physical dependence. This can cause unpleasant symptoms when a person tries to quit. Nicotine replacement therapy gives you nicotine — in the form of gums, patches, sprays, inhalers, or lozenges – but not the other harmful chemicals in tobacco. It can help relieve some of these symptoms so that you can focus on the psychological aspects of quitting.
How nicotine replacement works
Nicotine replacement therapy can help with the difficult withdrawal symptoms and cravings that 70% to 90% of smokers say is their only reason for not giving up cigarettes. Using NRT reduces a smoker’s withdrawal symptoms.
Although many smokers can quit smoking without using NRT, most of those who attempt quitting cannot do it on the first try. In fact, smokers usually need many tries — sometimes as many as 8 to 10 — before they are able to quit for good.
Lack of success is often related to the onset of withdrawal symptoms. And most quitters go back to smoking within the first 3 months of quitting. So don’t be discouraged if you start smoking again. Just try to stop again and make your attempt more successful by adding another method or technique to help you quit. You can reduce withdrawal symptoms with NRT and reduce their impact with support techniques. This gives you a better chance of quitting and staying quit.
Getting the most from nicotine replacement
Nicotine replacement therapy only deals with the physical addiction. It is not meant to be the only method used to help you quit smoking. You should combine it with other smoking cessation methods that help the psychological (emotional and habitual) part of smoking, such as a stop smoking program. Studies have shown that this approach — pairing NRT with a program that helps to change behavior — can double your chances of quitting and staying quit.
The US Agency for Healthcare Research and Quality (AHRQ) Clinical Practice Guideline on Smoking Cessation in 2000 recommended NRT for all adult smokers except pregnant women and people with heart or circulatory diseases. But more recent data suggest that NRT (specifically the nicotine patch) can be used safely under a doctor’s careful monitoring, even in people who have heart or blood vessel (cardiovascular) disease. These studies have found the benefits of quitting smoking outweigh the risks of NRT in patients with cardiovascular disease. When looking at these situations, the benefits of quitting smoking must outweigh the potential health risks of NRT for each person. As of late 2008, there is still not enough good evidence one way or the other to recommend using NRT in pregnant women. Pregnant smokers should talk with their doctors before using over-the-counter nicotine replacements.
The best time to start NRT is when you first quit. Many smokers ask if it is possible to start a program of nicotine replacement while they are still smoking. At this time the companies that make NRT products say that they should not be used if you are still smoking. There is some research being done with smokers using NRT while still smoking, but it is still too early to tell if this is dangerous to your health. The most important thing is to make sure that you are not overdosing on nicotine, which can affect your heart and blood circulation. It is safest to be under a doctor’s care if you wish to try smoking and using NRT while you are tapering down your cigarette use.
Often smokers first try to quit on their own then decide to try NRT a day or more into quitting. This method does not give you the greatest chance of success, but do not let this discourage you. There are still many options available for quitting smoking and staying quit.
Note that NRT has not yet been proven to help people who smoke less than 10 cigarettes per day. You may want to talk with your doctor about a lower dose of NRT if you smoke less than half a pack per day but feel you need nicotine replacement.
When may I begin using nicotine replacement therapy?
You may start using NRT as soon as you throw away that last cigarette. You do not need to wait a certain length of time to put on the patch or start using the gum, lozenge, nasal spray, or inhaler. You should double-check this information with the instructions on your chosen method of nicotine replacement, but in general there is no need to wait to start using NRT.
How do I know if I’m a light, average, or heavy smoker?
Some NRT products make their recommendations based on what kind of smoker you are. But there is no formal category in any textbook or group that defines a light, average, or heavy smoker. In general, a light smoker is someone who smokes less than 10 cigarettes per day. Someone who smokes a pack a day or more is a heavy smoker. An average smoker falls in between.
Sometimes a doctor will use the term pack year to describe how long and how much a person has smoked. A pack year is defined as the number of packs of cigarettes a person has smoked every day multiplied by the number of years he or she has smoked. Since 1 pack is 20 cigarettes, a person who has smoked 20 cigarettes a day for a year is considered to have smoked 1 pack year. Someone who has smoked 30 cigarettes a day (1½ packs) for 3 years has smoked 4.5 pack years (1½ x 3), and so on. This is just another way to figure out how high your risk of smoking-related disease might be.
Types of nicotine replacement therapy
The Food and Drug Administration (FDA) has approved 5 types of nicotine replacement therapy (NRT):
Nicotine patches (transdermal nicotine systems): Patches give a measured dose of nicotine through the skin. You are weaned off nicotine by switching to lower-dose patches over a course of weeks. Patches can be bought with or without a prescription. Many types and different strengths are available. Package inserts describe how to use the product, and list special considerations and possible side effects.
The 16-hour patch works well if you are a light-to-average smoker. It is less likely to cause side effects like skin irritation, racing heartbeat, sleep problems, and headache. But it does not deliver nicotine during the night, so it may not be right for those with early morning withdrawal symptoms.
The 24-hour patch provides a steady dose of nicotine, avoiding peaks and valleys. It helps with early morning withdrawal. But there may be more side effects such as disrupted sleep patterns and skin irritation.
Depending on body size, most smokers should start using a full-strength patch (15-22 mg of nicotine) daily for 4 weeks, and then use a weaker patch (5-14 mg of nicotine) for another 4 weeks. The patch should be put on in the morning on a clean, dry area of the skin without much hair. It should be placed below the neck and above the waist — for example, on the upper arm or chest. The FDA recommends using the patch for a total of 3 to 5 months.
Side effects are related to:
- the dose of nicotine
- the brand of patch
- skin characteristics (such as the person’s tendency to have a skin reaction to the patch)
- how long the patch is used
- how it is applied
Some possible side effects of the nicotine patch include:
- skin irritation — redness and itching
- racing heartbeat
- sleep problems or unusual dreams
- muscle aches and stiffness
What to do about side effects:
- Do not smoke while you are using a patch.
- Try a different brand of patch if your skin becomes irritated.
- Reduce the amount of nicotine by using a lower-dose patch.
- Sleep problems may be short-term and go away in 3 or 4 days. If not, and you’re using a 24-hour patch, try switching to a 16-hour patch.
- Stop using the patch and try a different form of NRT.
Nicotine gum: Nicotine gum is a fast-acting form of replacement in which nicotine is taken in through the mucous membrane of the mouth. You can buy it over the counter without a prescription. It comes in 2 mg and 4 mg strengths.
For best results, follow the instructions on the package insert. Chew the gum slowly until you note a peppery taste. Then “park” it inside your cheek, chewing it and parking it off and on for about 20 to 30 minutes. Food and drink can affect how well the nicotine is absorbed. You should avoid acidic foods and drinks such as coffee, juices, and soft drinks for at least 15 minutes before and during gum use.
If you smoke a pack or more per day, smoke within 30 minutes of waking up, or have trouble not smoking in restricted areas, you may need to start with the higher dose (4 mg). Chew no more than 20 pieces of gum in one day. Nicotine gum is usually recommended for 1 to 3 months, with the maximum being 6 months. Tapering the amount of gum chewed may help you stop using it.
If you have sensitive skin, you may prefer the gum to the patch.
Another advantage of nicotine gum is that it allows you to control the nicotine doses. The gum can be chewed as needed or on a fixed schedule during the day. The most recent research has shown that scheduled dosing works better. A schedule of 1 to 2 pieces per hour is common. On the other hand, with an as-needed schedule, you can chew when you need it most — when you have cravings.
Some possible side effects of nicotine gum:
- bad taste
- throat irritation
- mouth sores
- jaw discomfort
- racing heartbeat
Symptoms related to the stomach and jaw are usually caused by improper use of the gum, such as swallowing the nicotine or chewing too fast. The gum can also damage dentures and dental work.
Long-term dependence is one possible disadvantage of nicotine gum. In fact, research has shown that 15% to 20% of gum users who are able to quit smoking keep using the gum for a year or longer. Although the maximum recommended length of use is 6 months, continuing to use the gum is probably safer than going back to smoking. But since there is little research on the health effects of long-term nicotine gum use, most health care providers still recommend limiting its use to 6 months.
Nicotine nasal spray: The nasal spray delivers nicotine to the bloodstream as it is quickly absorbed through the nose. It is available only by prescription.
The nasal spray relieves withdrawal symptoms very quickly and lets you control your nicotine cravings. Smokers usually like the nasal spray because it is easy to use. But the FDA warns users that since this product contains nicotine, it can allow the addiction to continue. The FDA recommends that the spray be prescribed for 3-month periods and that it not be used for longer than 6 months.
The most common side effects last about 1 to 2 weeks and can include the following:
- nasal irritation
- runny nose
- watery eyes
- throat irritation
There is also the danger of using more than is needed. If you have asthma, allergies, nasal polyps, or sinus problems, your doctor may suggest another form of NRT.
Nicotine inhalers: Inhalers are available only by prescription. The nicotine inhaler is a thin plastic tube with a nicotine cartridge inside. When you take a puff from the inhaler, the cartridge puts out a nicotine vapor. Unlike other inhalers, which deliver most of the medicine to the lungs, the nicotine inhaler delivers most of the nicotine vapor to the mouth. Nicotine inhalers are the FDA-approved nicotine replacement method that is most like smoking a cigarette, which some smokers find helpful.
The recommended dose is between 6 and 16 cartridges a day, for up to 6 months.
The most common side effects, especially when first using the inhaler, include:
- throat irritation
- upset stomach
At this time, inhalers are the most expensive forms of NRT available. They are not the same as electronic cigarettes, which have not been proven in clinical trials to help with quitting and are not approved by the FDA.
Nicotine lozenges: Nicotine-containing lozenges as an over-the-counter aid to stop smoking are the newest form of NRT on the market. As with nicotine gum, the Commit® lozenge is available in 2 strengths: 2 mg and 4 mg. Smokers choose their dose based on how long after waking up they normally have their first cigarette.
The lozenge manufacturer recommends using it as part of a 12-week program. The recommended dose is 1 lozenge every 1 to 2 hours for 6 weeks, then 1 lozenge every 2 to 4 hours for weeks 7 to 9, and finally, 1 lozenge every 4 to 8 hours for weeks 10 to 12. The manufacturer also recommends the following:
- Stop all smoking when you begin to use the lozenge.
- Do not eat or drink for 15 minutes before using the lozenge. (Some drinks can reduce how well the lozenge works.)
- Suck on the lozenge until it is fully dissolved, about 20 to 30 minutes. Do not bite or chew it like a hard candy, and do not swallow it. The medicine is taken in through the tissues of the mouth.
- Do not use more than 5 lozenges in 6 hours, or more than 20 lozenges total per day.
- Stop using the lozenge after 12 weeks. If you still feel you need to use the lozenge, talk to your doctor.
- Do not use the lozenge if you keep smoking, chewing tobacco, using snuff, or use any other product containing nicotine (such as the nicotine patch or nicotine gum).
Possible side effects of the nicotine lozenge include:
- trouble sleeping
Which type of nicotine replacement may be right for you?
There’s no evidence that any one type of nicotine replacement therapy (NRT) is any better than another. When choosing which type of NRT you will use, think about which method will best fit your lifestyle and pattern of smoking. Do you want/need something to chew or occupy your hands? Or are you looking for once-a-day convenience?
Some important points to think about:
- Nicotine gums, lozenges, and inhalers are substitutes you can put into your mouth that allow you to control your dosage to help keep cravings under better control.
- Nicotine gums and lozenges are generally sugar-free, but if you are diabetic and have any doubts, check with the manufacturer.
- Nicotine nasal spray works very quickly when you need it.
- Nicotine inhalers allow you to mimic the use of cigarettes by puffing and holding the inhaler.
- Nicotine patches are convenient and only have to be applied once a day.
- Both inhalers and nasal sprays require a doctor’s prescription.
- Some people may not be able to use patches, inhalers, or nasal sprays because of allergies or other conditions.
Whatever type you use, take your NRT at the recommended dose, and for as long as it is recommended. If you use a different dose or stop taking it too soon, it can’t be expected to work like it should. If you are a very heavy smoker or a very light smoker, you may want to talk with your doctor about whether your NRT dose should be changed to better suit your situation.
Combining the patch and other nicotine replacement products: Using the nicotine patch along with shorter-acting products such as the gum, lozenge, nasal spray, or inhaler is another method of NRT. The idea is to get a steady dose of nicotine with the patch and to use one of the shorter-acting products when you have strong cravings.
The few studies that have been done on combination NRT used in the way described above have found that it may work better than a single product. Still, more research is needed to prove this and to find safe and effective doses. The combined use of NRT products has not yet been approved by the FDA. If you are thinking about using more than one NRT product, be sure to talk it over with your doctor first.
High-dose nicotine replacement therapy for heavy smokers: Another NRT option is to give smokers a higher dose based on the amount of nicotine that they have been getting from cigarettes. Sometimes this method has required larger doses of nicotine replacement than have been used before. High-dose NRT with patches has been studied with patients getting from 35 mg to 63 mg of nicotine per day. The research suggests that patients’ withdrawal symptoms go away with these higher doses and their cravings improve without harmful effects on the heart and circulation. Patient were carefully watched in these studies to make sure they were doing well and were not becoming ill or having any problems. This is still a new option that should be considered only with a doctor’s guidance and supervision.
Stopping nicotine replacement therapy
As mentioned before, most forms of NRT are meant to be used for limited periods of time. Use should be tapered down to a low dose before NRT is stopped. Research is still being done to refine the use of NRT. For example, even though the patch is usually used for 3 to 5 months, some studies have suggested that using it for 8 weeks or less works just as well. But other researchers have noted that the risk of relapse goes up when nicotine replacement is stopped, even after it has been used for 5 months. These differences have not been fully explained. More studies are needed to learn which smokers are likely to be successful using shorter or longer NRT than usual. If you feel that you need NRT for a different length of time than is recommended, it is best to discuss this with your doctor.
Bupropion (Zyban®) is a prescription anti-depressant in an extended-release form that reduces symptoms of nicotine withdrawal. It does not contain nicotine. This drug acts on chemicals in the brain that are related to nicotine craving. It can be used alone or together with nicotine replacement therapy (NRT). Bupropion works best if it is started 1 or 2 weeks before you quit smoking. The usual dosage is one or two 150 mg tablets per day.
This drug should not be taken if you have ever had seizures, heavy alcohol use, serious head injury, bipolar (manic-depressive) illness, or anorexia or bulimia (eating disorders).
Some doctors may recommend combination therapy for heavily-addicted smokers, such as using bupropion along with a nicotine patch and/or a short-acting form of NRT (such as gum or lozenges). The combination has been found to work better in some people than using any one part alone.
Varenicline is a newer prescription medicine developed to help people stop smoking. It works by interfering with nicotine receptors in the brain. This means it has 2 effects: it lessens the pleasurable physical effects a person gets from smoking, and it reduces the symptoms of nicotine withdrawal.
Several studies have shown varenicline can more than double the chances of quitting smoking. Some studies have also found it may work better than bupropion, at least in the short term.
Varenicline comes in pill form and is taken after meals, with a full glass of water. The daily dose increases over the first 8 days it is taken. The dose starts at one 0.5 mg pill a day for the first 3 days, then the 0.5 mg pill twice a day for the next 4 days. At the start of the second week, the dose is raised to 1 mg each morning and evening. For people who have problems with the higher dose, a lower dose may be used during the quit effort. Varenicline is given for 12 weeks, but people who quit during that time may get another 12 weeks of treatment to boost their chance of staying quit.
Reported side effects of varenicline have included headaches, nausea, vomiting, trouble sleeping, unusual dreams, flatulence (gas), and changes in taste. There have also been more recent reports of depressed mood, thoughts of suicide, attempted suicide, and changes in behavior in people taking varenicline. People who have these problems should contact their doctors right away. Although these side effects may happen, varenicline is usually well-tolerated.
Since varenicline is a newer drug, research has not been done to find out if it is safe to use along with nicotine replacement therapy (NRT) products. But the company that makes varenicline noted that people who used the drug along with NRT had more side effects such as nausea and headaches.
Other drugs that are not FDA-approved for helping smokers quit
For those who cannot use any of the FDA-approved drugs for helping smokers quit, or for those who have not been able to quit using them, there are other drugs that have shown promise in research studies. They are recommended by the Agency for Healthcare Research and Quality for this kind of use, but have not been approved by the FDA for this purpose and are used “off-label.” These drugs are only available with a prescription and are not recommended for pregnant smokers, teens, or people who smoke less than 10 cigarettes per day.
This is an older anti-depressant drug. When used in groups of smokers, it has been found to double their chances of success in quitting smoking. It is started 10 to 28 days before you stop smoking to allow it to reach a stable level in the body.
Some people have side effects such as fast heart rate, blurred vision, trouble urinating, dry mouth, constipation, weight gain or loss, and low blood pressure when they stand up. The drug can impair your ability to drive or operate machinery, and there are certain drugs that cannot be used along with it.
Be sure your doctor and pharmacist know exactly what you are taking before you start this medicine. Also be sure you know how to take it and how to taper it down when you are ready to stop. The dose of nortriptyline must be gradually lowered, since the drug cannot be stopped suddenly without the possibility of serious effects. The drug must be used with caution in people with heart disease.
Clonidine is also an older drug that is FDA approved for the treatment of high blood pressure. When used for smoking cessation, it can be given as a pill twice a day or as a once-a-week skin patch. In one study of heavy smokers who had failed in previous quit attempts, the group treated with clonidine was twice as likely to succeed in quitting smoking as the control group (which was given a fake pill) at the end of 4 weeks.
Be sure your doctor and pharmacist know exactly what you are taking before you start this medicine. The most common side effects of clonidine are constipation, dizziness, drowsiness, dry mouth, and unusual tiredness or weakness. There are rarely more severe side effects, such as allergic reactions, slow heart rate, and very high or very low blood pressure. Your doctor may want to watch your blood pressure while you are on this drug. The drug can impair your ability to drive or operate machinery
Clonidine can be started up to 3 days before you quit smoking but can also be started the day you quit. Like nortriptyline, it shouldn’t be stopped suddenly. The dose must be lowered over a period of 2 to 4 days to prevent a rapid increase in blood pressure, agitation, confusion, or tremors.
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