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Nicotine replacement therapy

Alternative Names

Smoking cessation - nicotine replacement; Tobacco - nicotine replacement therapy

Information

Nicotine replacement therapy involves the use of products that provide low doses of nicotine but do not contain the toxins found in smoke. The goal of therapy is to relieve cravings for nicotine and ease the symptoms when someone stops using cigarettes and smokeless tobacco.

In general, nicotine replacement therapy benefits moderate-to-heavy smokers (people who smoke more than 15 cigarettes a day) the most.

Facts about using nicotine replacement therapy:

• By not cheating on the very first day of nicotine-replacement use, you can increase the chance of quitting permanently by tenfold.
• The more cigarettes a patient smokes, the higher the dose of nicotine replacement that patient may need at the start of therapy.
• Adding a counseling program may boost the effectiveness of any nicotine replacement program.
• Do not smoke while using nicotine replacement. It can cause nicotine to build up to toxic levels.
• Nicotine replacement helps prevent weight gain while it is being used. However, people are still at risk for gaining weight when they stop all nicotine.
• The dose of nicotine should be slowly decreased.

TYPES OF NICOTINE REPLACEMENT THERAPY

Nicotine supplements come in several forms:

• Gum
• Inhalers
• Lozenges
• Nasal spray
• Skin patch

All of these work well if they are used properly. People are more likely to use the gum and patches correctly than other forms of nicotine supplements.

Nicotine Patch. Nicotine patches are applied and used in similar ways:

• A single patch is worn each day and replaced after 24 hours.
• To avoid skin irritation, place it on different hairless locations above the waist and below the neck each day.
• People can wear the patches for 24 hours, but some have odd dreams. However, people who wear the patch all the time have fewer withdrawal symptoms.
• People who smoke fewer than 10 cigarettes per day should start with a lower dose patch (for example, 14 mg).

Nicotine Gum or Lozenge. Nicotine gum (Nicorette and others) or lozenges (Commit and others) are available over the counter, without a prescription. Some people prefer lozenges to the patch, because they can control the nicotine dosage.

Tips for using the gum:

• If you are just starting to quit, chew 1 - 2 pieces each hour, but no more than 20 pieces a day.
• Chew the gum slowly until it develops a peppery taste. Then tuck it between the gum and cheek and store it there so that the nicotine can be absorbed.
• The goal is to stop using the gum by 6 months. Although using nicotine gum long-term is probably safer than smoking, research is needed to confirm this.
• Wait at least 15 minutes after drinking coffee, tea, soft drinks, and acidic beverages before chewing a piece of gum.
• People who smoke more than 25 cigarettes per day have better results with the 4 mg dose than with the 2 mg dose.

Nicotine Inhaler. The nicotine inhaler looks like a plastic cigarette holder. Nicotine cartridges are inserted into the inhaler and "puffed" for about 20 minutes, up to 16 times a day. The nicotine inhaler requires a prescription in the United States.

• The inhaler is relatively fast-acting. Blood nicotine levels peak about 20 minutes after using the inhaler. This is comparable to the gum and faster than the 2 - 4 hours seen with the patch.
• It satisfies oral urges.
• Most of the nicotine vapor is delivered to the mouth, not into the airways of the lung (although some people notice mouth or throat irritation and cough).

Using a combination of the inhaler and patch may be particularly effective.

Nicotine Nasal Spray. The nasal spray satisfies immediate cravings by providing doses of nicotine rapidly.

• It may be used along with slower-acting nicotine replacement therapies, such as the patch. Levels of nicotine peak within 5 - 10 minutes after using the spray.
• The spray can irritate the nose, eyes, and throat. Most people can tolerate these side effects, which usually go away within the first few days.

SIDE EFFECTS AND RISKS

Any nicotine supplement product may cause side effects. Patients using very high doses are more likely to have symptoms. Reducing the dose can prevent these symptoms. Side effects include:

• Headaches
• Nausea and other digestive problems
• Sleeplessness in the first few days, particularly with the patch, but the insomnia usually passes

SPECIAL CONCERNS

There has been some concern that the patch might be harmful for people with heart or circulatory disease, but studies are finding that it poses no danger for these individuals. However, unhealthy cholesterol levels (lower HDL levels) caused by smoking remain abnormal with the use of the nicotine patch.

Nicotine replacement may not be completely safe in pregnant women, although it has been used successfully in this group without harmful effects. There is an increase in the heart rates in unborn children of women who use the patch.

Keep all nicotine products away from children, especially small children. Nicotine is a poison. A parent should call a physician or a poison control center right away if a child has been exposed to a nicotine replacement product, even for a short time. Parents should watch for any symptoms, including stomach upset, irritability, headaches, a rash, or fatigue.

References

Burke MV, Ebbert JO, Hays JT. Treatment of tobacco dependence. Mayo Clin Proc. 2008;83:479-483.

Moore D, Aveyard P, Connock M, Wang D, Fry-Smith A, Barton P. Effectiveness and safety of nicotine replacement therapy assisted reduction to stop smoking: systematic review and meta-analysis. BMJ. 2009;338:b1024.

Hays JT, Ebbert JO, Sood A. Treating tobacco dependence in light of the 2008 US Department of Health and Human Services clinical practice guideline. Mayo Clin Proc. 2009;84:730-735.

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