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Options in Nicotine Therapy

About two-thirds of smokers who try to quit on their own aren't successful, and withdrawal symptoms typically cause their relapses. By using nicotine replacement therapy (NRT) to reduce these symptoms, smokers who try to quit have a better chance of succeeding.

Nicotine is highly addictive, whether used by smoking, vaporizing, or chewing in various tobacco products. Nicotine is absorbed in a matter of only a few seconds and high levels of nicotine in the blood are achieved when a cigarette, tobacco, or nicotine solution is smoked, vaporized, or chewed. Those high levels of nicotine stimulate the addiction centers of the brain. When smokers try to quit smoking, they experience both psychological and physical withdrawal symptoms caused by the lack of nicotine. Up to 90% of smokers say that the withdrawal symptoms are their only reason for not quitting.

How severe the withdrawal symptoms are depends on the nicotine levels in the blood. That level depends on the length of time between cigarettes, how deeply a person inhales, how many cigarettes are smoked each day, and the brand smoked. NRT delivers nicotine to the body more slowly than does smoking.

Because of the difficulty in overcoming nicotine addiction, NRT is recommended for anyone trying to quit smoking. If you're pregnant or have heart disease, you should check with your health care provider before using NRT though. Successful quitters have developed a plan on how to quit, set a quit date, and started using NRT on their quit date.

In the past couple of years, there have been numerous "smokeless" cigarettes or electronic cigarettes available to purchase. The FDA has not approved these products to use for smoking cessation. There may be other potential toxic harmful chemicals that may not be safe. Consumer have no way of knowing how much nicotine they're inhaling when they use these products. Inhaling results in rapid nicotine absorption and stimulation of the addiction center in the brain is very likely and addiction to nicotine may continue.

Because NRT deals with only the physical aspects of addiction, it's not intended to be used alone. Studies have shown that pairing NRT with behavior counseling, using a quit help phone line, smart app for your cell phone, or any other quit support service can increase your chance of successfully quitting smoking. 

Side Effects of NRT 

NRT may cause some of these side effects:

  • Skin irritation and itching

  • Dizziness

  • Racing heartbeat

  • Sleep problems

  • Headache

  • Nausea

  • Vomiting

  • Muscle aches and stiffness

OTC products

These NRT products are available without a prescription:

Nicotine patch

Nicotine patches provide a measured dose of nicotine through the skin and can be purchased without a prescription. They are available in 3 different strengths so that you can reduce the dose gradually. As the nicotine doses are lowered over a course of several weeks, the smoker is weaned off nicotine.

A lower dose patch, like 14mg or 7mg, may work well if you are a light to average smoker; it's less likely to cause side effects. Wear each patch for 24 hours to provide a steady dose of nicotine around the clock, so you can avoid highs and lows. If you have trouble sleeping due to vivid dreams or another reason, you can take the patch off at night, but remember that it may not help you through withdrawal symptoms you experience first thing in the morning.

Depending on body size, most smokers start by using a full-strength patch (21 mg of nicotine) daily for 4 weeks, then use a weaker patch (14 mg then 7mg) for another 4 weeks. If you have difficulty tapering and stopping the doses because you feel like smoking, ask your doctor or pharmacist if it is OK to use the patches for more than 3 to 4 months. You should place the patch on a clean, dry area of the skin without much hair. The patch should go on your upper arms, chest, abdomen, or back and be rotated to different locations with each new application to avoid skin irritation. 

Possible side effects of nicotine patches include:

  • Skin irritation and itching

  • Dizziness

  • Racing heartbeat

  • Sleep problems

  • Muscle aches and stiffness

Nicotine gum

Nicotine gum is a fast-acting form of replacement in which nicotine is absorbed through the mouth. You can buy the gum without a prescription; it comes in 2 mg and 4 mg strengths. The gum is recommended for 1 to 3 months, with the maximum being 6 months.

No more than 24 pieces should be used in 1 day. For best results, chew the gum slowly until you note a peppery taste, then "park" it against your cheek. Alternate between chewing and parking for about 20 to 30 minutes. If the gum is initially chewed too fast, a headache can result from the rush of nicotine. 

Nicotine gum is better than the patch for people with sensitive skin. Nicotine gum also allows you to control your dose of nicotine, because you can chew it as you need it. One drawback is that the gum may lead to long-term dependence. Up to 20% of people who use the gum keep on chewing for at least a year after quitting smoking.

Possible side effects of nicotine gum include:

  • Throat irritation

  • Mouth ulcers

  • Hiccups

  • Nausea

  • Jaw discomfort

  • Racing heartbeat

Nicotine lozenges

The lozenge is the newest form of NRT, and comes in 2 mg and 4 mg strengths and is most similar to nicotine gum. The lozenge should be used over a 12-week period, with 1 lozenge every 1 to 2 hours for the first 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.

For best results, "park" each lozenge against your cheek. It will take 20 to 30 minutes to completely dissolve and the nicotine absorbed. If the lozenge is crunched or chewed, a headache can result from the rush of nicotine. You should not smoke or use other tobacco products when using the lozenge. If you feel that you need to continue to use the lozenge after 12 week, you should talk with your health care provider.

Possible side effects of the lozenge include:

  • Difficulty sleeping

  • Nausea

  • Hiccups

  • Coughing

  • Heartburn

  • Headache

  • Flatulence

Prescription products

These NRT products require a prescription from your doctor.

Nicotine nasal spray

The nasal spray delivers nicotine quickly to the bloodstream, because it's absorbed through the nose. It's available by prescription only. Check with your health insurance carrier to see if the spray is included in your plan.

The nasal spray gives immediate relief of withdrawal symptoms and offers a sense of control over nicotine cravings. The FDA recommends that the spray be prescribed for 3-month periods and that it not be used for more than 6 months.

Common side effects of the nasal spray:

  • Nasal irritation (possible nose bleeds) 

  • Runny nose

  • Watery eyes

  • Sneezing

  • Throat irritation

  • Coughing

These side effects last one to two weeks. Your health care provider may suggest that you use another form of NRT if you have asthma, allergies, nasal polyps, or sinus problems.

Nicotine inhalers

Nicotine inhalers are plastic tubes with nicotine cartridges inside them. When you puff on 1, its cartridge provides nicotine in a powder. Unlike other types of inhalers, which deliver most of their medication to the lungs, nicotine inhalers deliver most of their nicotine powder to the mouth. The recommended dose is 4 to 20 cartridges a day for up to 6 months. They are available only by prescription. Check with your health insurance carrier to see if the inhaler is included in your plan, as this is the most expensive form of NRT available.

Common side effects of the inhaler include:

  • Coughing

  • Throat irritation

  • Upset stomach

Choosing a method

When choosing which type of NRT best suits you, think about which method best fits your lifestyle and smoking pattern.

Nicotine patches are convenient and have to be applied only once a day. With nicotine gum, lozenges, and inhalers, you can control your dosage. Nicotine nasal sprays work very quickly when you need them. With nicotine inhalers, you can mimic the use of cigarettes by puffing and holding the inhaler.

While many of the NRT options are available without a prescription (see above), it's always best to consult with your health care provider to see which of these options may be best for you.

Online Medical Reviewer: Berry, Judith, PhD, APRN
Online Medical Reviewer: Stock, Christopher J., PharmD
Last Review Date: 12/12/2013
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