Tobacco addiction is mental and physical. Physical dependence can cause you to have withdrawal symptoms if you try to quit, and this can lead back to using tobacco. For most people, the best way to quit will be some combination of medicine, a method to change personal habits, and emotional support.
Nicotine replacement therapy

Nicotine replacement is a way to get nicotine without the other harmful chemicals in tobacco. For cigarette smokers, nicotine replacement therapy (NRT) has been proven to help reduce withdrawal symptoms. Together with counseling or other support, it doubles the chances that a smoker will quit.

Fewer studies have been done on how much NRT helps smokeless tobacco users quit. Since both smokers and smokeless users are addicted to nicotine, some smokeless tobacco users think it makes sense to try it.

The Food and Drug Administration (FDA) has approved these NRT products as effective aids for helping people to quit smoking:

• Nicotine gum
• Nicotine patch
• Nicotine lozenges
• Nicotine inhaler
• Nicotine nasal spray

(For more detailed information on these products, see our document, Guide to Quitting Smoking.)

None of these products has been FDA approved specifically to help people quit smokeless tobacco. This is because it has not been proven how well they work to help quit smokeless tobacco. The results of some small studies have been mixed, and larger studies are needed. Still, NRT may be useful in helping you quit, or at least in helping reduce your cravings.

Nicotine gum, patches, and lozenges can be bought over the counter (without a prescription). Nicotine nasal spray and nasal inhalers are available only with a doctor’s prescription.

For smokeless tobacco users, certain types of NRT may help more than others. If you look at the way the tobacco is used, nicotine gum and lozenges are most like using smokeless tobacco. They also let you control your dose to help keep nicotine cravings at bay. The nicotine inhaler may not be as useful for smokeless tobacco users, as it is designed to look and feel like a cigarette filter tip. The nicotine patch gives a steady dose of nicotine, but may not help with strong cravings. Still, the patch may be more useful for people who prefer once-a-day convenience. A 2007 study compared higher-dose nicotine patches with the usual NRT doses in heavy users of smokeless tobacco. The researchers found that higher doses were more helpful in reducing withdrawal symptoms.

No matter which type of NRT you choose, make sure to follow the package instructions and don’t use any tobacco, including smokeless tobacco, when using nicotine replacement. You may want to talk with your doctor, dentist, or pharmacist before using any of these products.

Getting the most from nicotine replacement
Nicotine replacement therapy only deals with the physical part of withdrawal. It is not meant to be the only thing you use to help you quit. Nicotine replacement works best when it is used with other quitting aids such as group sessions or counseling. NRT reduces withdrawal symptoms so you can focus on coping with the mental and emotional aspects of quitting.

If you choose to use it, NRT works best if it is started at the very same time you try to quit. Often tobacco users first try to quit on their own, and then decide to try NRT. By then, withdrawal symptoms have already started, and NRT may not help as much.

You should not use NRT if you plan to continue to use any tobacco product. The combined dose of nicotine can be dangerous; you can get too much of it.

Tobacco users who are pregnant or have heart disease should talk to a doctor before using over-the-counter nicotine replacement. You may need a different type of help with quitting, and your doctor may need to see you more often while you take the medicine.
Can you get too much nicotine from NRT?

NRT products are supposed to roughly match the amount you get from NRT to the amount you typically took in through tobacco. It can be more of a challenge to get the dose right for smokeless tobacco users, since NRT products are labeled for smokers.

In general, a person who uses more than 3 cans of snuff or 3 pouches of tobacco a week is thought of as a heavy user, and would typically use the higher doses of NRT (for heavy smokers). Those who use 2-3 cans or pouches per week would usually try the moderate doses, and those who use less than 2 would start with the smallest doses of NRT. If you have decided to try NRT, discuss your dose with your doctor before you quit tobacco.

To avoid withdrawal symptoms, you want to aim for a nicotine dose fairly close to what you got from snuff or tobacco use. You don’t want to get more than that, because higher doses of nicotine can cause harm. A bit too much can cause some of the milder symptoms below. An overdose can cause death. Because of their small size, overdose is more of a problem with children and pets.

Nicotine absorbs through the skin, so you must store and dispose of your NRT safely. Keep new NRT and any used or empty bottles, cartridges, patches, etc., safely away from children and pets. Also, don’t use a heat source (like a heating pad or heat lamp) on the skin under your nicotine patch – the extra blood supply could cause more nicotine to absorb.

It would be rare for an adult trying to quit tobacco to get a serious overdose using NRT. But with liquid forms that can absorb quickly through the skin, even that could happen. All forms of NRT can cause harm if too much is taken in.

Here are some symptoms of too much nicotine:

• Headache
• Nausea and vomiting
• Belly pain
• Diarrhea
• Fast or irregular heartbeat
• Cold sweat
• Pale skin and mouth
• Weakness
• Tremor (shaking)
• Confusion
• Disturbed vision and hearing
• Seizures
• Breathing stops

Call Poison Control and get emergency help if you suspect an overdose. If you are taking NRT as directed and are still having mild symptoms such as headache, vomiting, diarrhea, or sweating, lower your dose and talk to your doctor.

Prescription medicines
Bupropion: Bupropion (Zyban® or Wellbutrin®) 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. Bupropion is FDA approved as an aid in quitting smoking, but it is not clear if it is useful for smokeless tobacco users. A 2007 study found that it helped reduce cravings and weight gain in people who were trying to quit smokeless tobacco. But in that clinical trial, the group taking bupropion had about the same success rate as the group taking placebo (sugar pills).

Bupropion works best in smokers if it is started 1 or 2 weeks before the quit date. The usual dosage is one or two 150 mg tablets per day. Talk to a doctor to find out if this might be an option for you.

Bupropion can be used alone or with NRT. You should not take it if you have ever had seizures, serious head injury, bipolar (manic-depressive) illness, anorexia or bulimia (eating disorders), or problems with heavy alcohol use.

Varenicline: Varenicline (Chantix™) is a prescription medicine taken as a pill twice a day. It works by interfering with nicotine receptors in the brain. It lessens the physical pleasure of taking in nicotine and helps lessen the symptoms of nicotine withdrawal. Studies have shown it works as least as well as bupropion (if not more so) in helping people quit smoking, at least in the short term. Like bupropion, it must be started at least a week before quitting.

A small study of people who were not trying to quit smokeless tobacco found that a few quit or cut down their tobacco intake while taking varenicline. Larger studies in people who actually want to quit smokeless tobacco would help find out how useful varenicline might be.

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