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Nicotine Patches and Chewing Gum

  • Bruce Mirken
  • Posted March 11, 2013

"Quitting smoking is easy," Mark Twain once said. "I've done it a thousand times." Maybe for you it's been dozens of times -- or only six or seven. But if you've tried and failed, it might be time to stop relying on willpower alone. Research has shown that a number of different stop-smoking aids, used in combination with counseling, can roughly double your chance of stubbing out that cigarette for good.

The U.S. Surgeon General acknowledges that for some people, tobacco can be as addictive as heroin or cocaine. While some smokers successfully stop on their own, studies show that many more fail. Using a nicotine substitute (nicotine replacement therapy), coupled with counseling or stop-smoking classes, can be powerful tools against tobacco addiction. In fact, people who are moderately or severely dependent on nicotine should routinely be prescribed nicotine replacement therapy to help them stop smoking, according to a study in the American Family Physician.

Nicotine replacement therapy (NRT) isn't just for adults -- it's also an effective weapon for treating smoking addiction in teens. About 20 percent of high school students smoke, and half of adults who smoke develop an addiction by their 18th birthday, making adolescents an important target to kick the habit. While NRT product labels discourage NRT for teens, the latest medical guidelines recommend it as a safe and effective treatment option for them.

Nicotine replacement therapy, which includes nicotine skin patches, sprays, tablets, inhalers and gum, can make an enormous difference in your ability to quit smoking. A study in the journal American Family Physician found smokers who used NRT were 2.27 times more likely to quit as those who didn't. What's more, people who used any type of nicotine replacement therapy were 1.72 times more likely to be free of smoking after six months or more as people who didn't use a nicotine substitute. A large-scale 2008 review of randomized trials found that the use of NRT increased the rate of quitting by 50 to 70 percent.

If you have a bad reaction to nicotine patches or gum, as some people do, don't give up: Talk with your physician about alternatives. It's important to remember that although no chemical is going to do it all for you, you don't have to face your smoking demons alone. Your health provider will help you design a carefully thought-out plan to help you stop smoking -- one that gives you the best chance of succeeding.

The most common medical approach to easing nicotine withdrawal is by temporarily getting the drug through some means other than cigarettes. This helps calm physical withdrawal symptoms such as sleep difficulties, irritability, headache, and restlessness, allowing you to deal more easily with the psychological aspects of kicking the habit. Nicotine replacement therapy is generally quite safe, though some people experience serious side effects ranging from depression and palpitations to irritability, sinusitis, and breathing problems. There are also risks for pregnant women -- some studies show an increased chance of low birth weight and preterm birth associated with NRT. Women who are pregnant, as well as people with certain heart, endocrine, or circulatory problems, should be carefully tested and evaluated before starting NRT because of potential the side effects associated with it.

NRT comes in several different forms:

Nicotine gum. The oldest form of nicotine replacement, nicotine gum is available over the counter. Proper use is important: Chew the gum a few times, till a peppery or minty taste becomes apparent, then "park" it between your cheek and gums. This allows the nicotine to be absorbed through the mucous membranes of the mouth. Swallowing nicotine gets far less of it into the bloodstream and can cause gastrointestinal problems.

Two strengths are available: 2 milligrams is usually enough for relatively light smokers, but the higher 4 mg strength is recommended for those who smoke more than 25 cigarettes daily (some suggest the stronger gum for those whose who smoke as little as 15 cigarettes per day). Acidic beverages like coffee, tea, and fruit juice interfere with nicotine absorption and should be avoided during use.

Nicotine inhaler. Similar to inhalers used for asthma medications, nicotine inhalers are available only by prescription. Each puff contains a very small amount of nicotine, so frequent use is necessary -- which may be an advantage for ex-smokers looking for ways to keep their hands busy. Effectiveness declines at temperatures below 50 degrees Fahrenheit. As with the gum, avoid acidic beverages.

Nicotine patch. A nicotine patch, applied to an inconspicuous area of the skin, provides a steady, continuous level of the drug. Patches are available both by prescription and over the counter. They come in several different dosage levels and in 16-hour and 24-hour versions -- the 16-hour version being most commonly recommended for light smokers and those who are bothered by side effects overnight. (According to a June 2001 study in American Family Physician, wearing the patch 16 hours a day during waking hours is equally as effective as wearing it 24 hours a day.)

At least one brand comes in three different strengths, allowing a gradual tapering off, but research has been inconclusive as to whether such a gradual weaning increases the chance of success. Side effects are usually minor, such as local skin irritation where the patch is worn, although some people become jittery when wearing the patches.

Nicotine nasal spray. Available only by prescription, nicotine nasal spray is easy to use, provides immediate relief from cravings, and is just as effective as the nicotine patch. Side effects can include runny nose, sneezing, and cough.

Cautions about nicotine replacement therapy: signs of overdose include nausea, abdominal pain, vomiting, diarrhea, cold sweats, headache, dizziness, confusion, disturbed hearing, palpitations, and difficulty breathing. Call your doctor immediately if you experience these symptoms, or if you experience any other unusual side effects.

Non-nicotine therapies

Bupropion (Zyban). Available by prescription, bupropion (brand name Zyban) is recommended as a first-line treatment by the Surgeon General and U.S. Public Health Service. The drug, also sold as an antidepressant under the name Wellbutrin, helps relieve nicotine cravings. Bupropion should not be used by those with a history of seizure disorders or eating disorders, and -- as with NRT -- caution is advised for pregnant women. Additionally, the Food and Drug Administration issued an alert in 2005 for bupropion. Citing several recent scientific reports, the FDA says bupropion may lead to an increase in suicidal tendencies for those with depression. The drug can be used in combination with one of the nicotine products, and research from the American Cancer Society and others suggests that such a combination is more effective than either used alone.

Chantix (varenicline tartrate). This prescription smoking cessation drug is only the second nicotine-free one to gain FDA approval. It works two ways: It cuts the pleasure of smoking and reduces withdrawal symptoms. The most commonly reported side effects include nausea, headache, vomiting, gas, insomnia, and a change in taste perception. In 2008, however, the FDA issued a public advisory to report the risk of severe changes in mood and behavior in patients taking Chantix, and the manufacturer updated its prescribing information to include warnings about these risks. Patients should tell their doctor about any history of psychological illness before starting Chantix and should be alert to any changes in mood or behavior and report them to their doctor immediately.

Other medications. Though not approved by the FDA as stop-smoking aids, two other drugs, clonidine -- normally used to treat hypertension -- and nortriptyline -- a tricyclic antidepressant -- have shown some usefulness. Because of concerns about side effects, the Public Health Service recommends these only as second-line treatments, to be used by those who cannot take NRT or bupropion SR, or for whom the approved medications have failed.

It may take a few tries to figure out what method or combination works for you, but once you quit for good, you can happily quote Mark Twain on many other subjects besides smoking.

References

American Lung Association. Smoking and Teens Fact Sheet. March 2009. http://www.lungusa.org/site/c.dvLUK9O0E/b.39871/

U.S. Surgeon General, You Can Quit Smoking, www.surgeongeneral.gov/tobacco/consquits.htm

Price JH et al. Pediatricians Use of the 5 As and Nicotine Replacement Therapy with Adolescent Smokers. Journal of Community Health. 32(2):85-101. April 2007. http://www.ncbi.nlm.nih.gov/pubmed/17571523

U.S. Surgeon General, Tips for the First Week, www.surgeongeneral.gov/tobacco/1stweek.htm

Stapleton, John A., et al, Dose effects and predictors of outcome in a randomized trial of transdermal nicotine patches in general practice, Addiction (1995) 90, p. 31-42.

U.S. Public Health Service, Clinical Practice Guidelines: Treating Tobacco Use and Dependence, June, 2000, http://hstat.nlm.gov/tempfiles/is/tempBrPg62045.html not working (note: there is also a link to this document on the U.S. Surgeon General's tobacco site, above)

Prochazka, Allan V., New developments in smoking cessation, Chest 117(4) April 2000 Supplement, 169S-175S.

American Cancer Society, Quitting Smoking, 11/2/2000, www.cancer.org/tobacco/quitting.html

Food and Drug Administration. Bupropion hydrochloride (marketed as the antidepressant Wellbutrin) Information. July 2005. http://www.fda.gov/cder/drug/infopage/bupropion/default.htm

American Lung Association. Nicotine Replacement Therapy (NRT) and Other Medications Which Aid Smoking Cessation. July 2006.

Stead, LF, et al. Nicotine Replacement Therapy for Smoking Cessation. Cochrane Database Systematic Review. 2008 Jan 23 (1): CD 000146.

FDA. Important information on Chantix (varenicline). May 16, 2008.

Gaither, KH et al. Does the Use of Nicotine Replacement Therapy During Pregnancy Affect Pregnancy Outcomes? Maternal and Child Health Journal. 13(4): 497-504. July 2009. http://www.ncbi.nlm.nih.gov/pubmed/18478321

Lerman C et al. Matching Nicotine Replacement Treatment to Particular Smokers. Annals of Internal Medicine. Volume 140, Issue 6. March 16, 2004. http://www.annals.org/cgi/content/full/140/6/I-47

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