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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, when used by smoking or chewing in tobacco products, is highly addictive, according to the American Cancer Society (ACS). The rapid absorption and high levels of nicotine in the blood that are achieved when a cigarette is smoked or tobacco is chewed, stimulates 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 percent of smokers say that the withdrawal symptoms are their only reason for not quitting, according to the National Cancer Institute (NCI).

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, according to the NCI. NRT delivers nicotine to the body more slowly than does smoking, which takes only a few seconds.

Because of the difficulty in overcoming nicotine addiction, NRT is recommended for anyone trying to quit smoking, according to the U.S. Agency for Healthcare Research and Quality. 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. 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 can increase your chance of successfully quitting smoking. 

Side Effects of NRT 

NRT may cause some of these side effects, according to NCI:

  • 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. As the nicotine doses are lowered over a course of several weeks, the smoker is weaned off nicotine.

The 16-hour patch may work well if you are a light to average smoker; it's less likely to cause side effects, but it may not be helpful for early morning withdrawal symptoms. 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 (15 to 22 mg of nicotine) daily for four weeks, then use a weaker patch (5 to 14 mg) for another four weeks. The Food and Drug Administration (FDA) recommends using the patch for no longer than three to five months. You should place the patch on a clean, dry area of the skin without much hair, the NCI says. 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 one to three months, with the maximum being six months.

No more than 24 pieces should be used in one 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, the NCI says. One drawback is that the gum may lead to long-term dependence. Up to 20 percent 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 one lozenge every one to two hours for the first six weeks, then one lozenge every two to four hours for weeks seven to nine, and finally one lozenge every four to eight hours for weeks 10 to 12, according to the American Cancer Society.

For best results, "park" each lozenge against your cheek. It will take 20-30 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 three-month periods and that it not be used for more than six months.

Common side effects of the nasal spray, according to the NCI, include:

  • 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 one, 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 four to 20 cartridges a day for up to six 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.

NRT shouldn't be used if you continue to smoke or chew tobacco.
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.