Nicotine Replacement Therapy

The U.S. Agency for Healthcare Research and Quality (AHRQ) Clinical Practice Guideline on Smoking Cessation recommends NRT for all smokers except pregnant women and people with heart or circulatory diseases.¹

Nicotine replacement therapy (NRT) provides nicotine – in the form of gums, patches, pills, sprays, inhalers or lozenges – without the other harmful components of tobacco. These nicotine substitutes are designed to treat the very difficult cravings and withdrawal symptoms that 70% to 90% of smokers say is their only reason for not giving up cigarettes.¹

NRT solely deals with the physical aspects of addiction and is not intended to be the only method used to help individuals quit smoking. It should be combined with other smoking cessation methods that address the psychological component of smoking. Studies have shown that pairing NRT with a program that helps to change behavior can double the chances of successfully quitting.¹

Nicotine replacement therapy should not be used if individuals plan to continue to smoke or use another tobacco product. The combined dose of nicotine could be dangerous to one's health.¹

Types of Nicotine Substitutes

• Nicotine Nasal Spray (prescription only)
• Nicotine Inhalers (prescription only)
• Nicotine Lozenges
• Nicotine Patches
• Nicotine Gum

Nicotine Nasal Spray

General Information:

The nasal spray, which is only available through prescription, delivers nicotine quickly to the bloodstream as it is absorbed through the nose. The nasal spray is designed to immediately relieve withdrawal symptoms and give smokers a sense of control over their nicotine cravings. However, the FDA cautions that since this product contains nicotine, it can be addictive. It is recommended that the spray be prescribed for 3-month periods and not used for longer than 6 months.¹

Empirical Evidence on Effectiveness

Nicotine nasal spray is among the five recommended first-line smoking cessation aids.² Abstinence rates achieved with nasal sprays are comparable to those achieved by other forms of nicotine replacement therapy.³ There is evidence of variability in abstinence rates following nasal spray treatment, possibly due to the adverse side effects commonly present in the first week of treatment.⁴ Laboratory studies have found that positive subjective effects following a dose of nasal spray were associated with increased subsequent self-administration of nasal spray.⁵

Possible Side Effects

• Nasal irritation
• Runny nose
• Watery eyes
• Sneezing
• Throat irritation
• Coughing

Links to Brand Name Nasal Sprays

Nicotrol Nasal Spray: http://www.nicotrol.com

• Company reports that smokers who use nicotrol nasal spray with a comprehensive behavioral smoking cessation are more successful in quitting smoking.

Nicotine Inhalers

General Information

First introduced in 1998, the nicotine inhaler (nicknamed the "puffer") is a plastic tube with a nicotine cartridge inside. It is available by prescription only. When users puff on the inhaler, the cartridge provides nicotine vapor, which unlike other inhalers, delivers most of the medication to the mouth rather than the lungs. Nicotine inhalers are the closest thing to smoking a cigarette in terms of behavior, which some smokers find helpful. Inhalers are the most expensive form of nicotine replacement therapy on the market today.¹

Empirical Evidence on Effectiveness

Research studies have found nicotine inhalers effectively and safely achieved sustained reduction in smoking over 24 months.² A study of 223 adult smokers reported 24% success rates of smoking cessation at 3 months compared to only 10% for a placebo inhaler.³

Possible Side Effects

• Coughing
• Throat irritation
• Upset stomach

Links to Brand Name Nicotine Inhalers

Nicotrol Inhaler: http://www.nicotrol.com

• Website includes prescription information and demonstration video

Nicotine Lozenges

General Information

This is the newest form of nicotine replacement therapy on the market. The first over-the-counter nicotine lozenge was recently approved by the FDA as an aide in smoking cessation. The over-the-counter lozenge (Commit lozenge) is available in 2 strengths: 2 mg and 4 mg.¹

The lozenge manufacturer recommends using it as part of a 12-week program. The recommended dose is one lozenge every 1-2 hours for 6 weeks, then one lozenge every 2-4 hours for weeks 7 to 9, and finally, one lozenge every 4-8 hours for weeks 10 to 12.¹

Empirical Evidence on Effectiveness

A recent report demonstrated a nicotine lozenge to be superior to placebo in reducing smoking urge, as well as significantly improved vigilance and psychomotor performances.² Also, research has found that nicotine lozenges significantly increased quit rates relative to placebo at six weeks and one year among light smokers (<15 cigarettes/day).³ Nicotine lozenges have demonstrated effectiveness for those who have a history of past failure with pharmacologic treatment.⁴

Possible Side Effects

• Trouble sleeping
• Nausea
• Hiccups
• Coughing
• Heartburn
• Headache
• Flatulence (gas)

Links to Name Brand Nicotine Lozenges

Commit Lozenge: http://www.commitlozenge.com

• Convenient packaging for discrete use
• Available in mint flavor

Nicotine Patches

General Information

Patches provide a measured dose of nicotine through the skin. Each adhesive patch contains a specific amount of nicotine embedded in a pad or gel that steadily travels out of the patch, through the individual's skin, and into their bloodstream. The patch may be placed anywhere on a person's torso that is clean, dry, and non-hairy, but most are recommended to be placed on the upper arm. Patches can be purchased without a prescription; several types and different strengths are available. Package inserts describe how to use the product as well as special considerations and possible side effects.¹

Empirical Evidence on Effectiveness

Nicotine transdermal patches have been shown to increase the success rates of smoking cessation treatments,² and several clinical trials have found that smokers wearing patches report lower levels of craving to smoke relative to participants in control conditions.^{3, 4, 5}

In terms of direct effects on cravings, research has indicated that nicotine patches can reduce general levels of cravings in participants abstinent for 90 minutes or 24 hours.^{6, 7}

Possible Side Effects

• Skin irritation – redness, itching
• Dizziness
• Racing heartbeat
• Sleep problems or unusual dreams
• Headache
• Nausea
• Vomiting
• Muscle aches and stiffness

Links to Brand Name Nicotine Patches

Habitrol: http://www.habitrol.com

• Round patches come in three strengths: 21, 14, or 7 mg of nicotine per patch
• Worn 24 hours per day

Nicoderm CQ: http://www.nicodermcq.com

• Rectangular patches come in three strengths: 21, 14, or 7 mg of nicotine per patch
• Worn 24 hours per day

Nicotine Gum

General Information

Nicotine gum is a fast-acting form of replacement therapy that acts through the mucous membrane of the mouth. It can be bought over-the-counter without a prescription and comes in 2 mg and 4 mg strengths. The gum is chewed slowly until a "peppery" taste is detected, then "parked" against the inside of the cheek, with intermittent chewing on and off for about 30 minutes. Those who smoke more than a pack per day should start off with the 4 mg strength, using no more than 20 pieces per day. Maximum recommended usage is 6 months. Nicotine gum may be preferred over the patch for those with sensitive skin.¹

Empirical Evidence on Effectiveness

Smoking abstinence success rates among participants using over-the-counter nicotine gum have been found to be consistently higher than those using prescription gum.² Sixteen percent of over-the-counter gum users were abstinent at 6-weeks compared to 7% of prescription gum users. Another study reported both nicotine gum and a placebo gum were equally effective at reducing acute cravings for cigarettes.³ Researchers tested a new prototype rapid-release nicotine gum and found it to be more effective at reducing cue-provoked cravings than the standard nicotine gum.⁴

Possible Side Effects

• Bad taste
• Throat irritation
• Mouth sores
• Hiccups
• Nausea
• Jaw discomfort
• Racing heartbeat

Links to Brand Name Nicotine Gums

Nicorette: http://www.nicorette.com

• Available in 4 different flavors (Fruit Chill, Freshmint, Original, Mint)
• Includes information on online support program

Nicotrol: http://www.nicotrolgum.com

• Same exact gum as nicorette, but repackaged under a different name
• Available in two flavors (Mint, Original)

Habitrol: http://www.habitrolgum.com

• Available in Mint and Fruit flavors

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Research Studies on Nicotine Replacement Therapy

 

Meta-analysis concludes that all forms of NRT can help people quit smoking

The Cochrane Reviews conducted a review of 132 trials of NRT, which included over 40,000 participants.  Evidence was found that all forms of NRT increased the likelihood that individuals would have successful quit attempts.  Chances of stopping smoking were increased by 50-70% with the use of any NRT product.  The review did not find evidence for any differences in effectiveness between the various types of nicotine replacement therapy.

Stead, L.F., Perera, R., Bullen, C., Mant, D., Lancaster, T. (2007). Nicotine replacement therapy for smoking cessation. Cochrane Database of Systematic Reviews 2007, Issue 4.