Guide for Quitting Smoking

What About Nicotine Replacement Therapy?

If you're hooked on nicotine or if you've tried quitting before, think about using nicotine replacement therapy. This method gives you a small dose of nicotine to help cut down the urge to use tobacco once you quit. Nicotine gum, lozenges, and "the patch" are sold over the counter at your drug store. Other forms of nicotine replacement, such as nasal sprays and inhalers, need a doctor's prescription. Nicotine replacement therapy costs about the same as a pack of cigarettes per day. You will only have to use replacement therapy for a short period of time.

How Nicotine Replacement Works

Nicotine substitutes treat the very difficult withdrawal symptoms and cravings that 70% to 90% of smokers say is their only reason for not giving up cigarettes. By using a nicotine substitute, a smoker's withdrawal symptoms are reduced.

While a large number of smokers are able to quit smoking without nicotine replacement, most of those who attempt quitting are not successful on the first try. In fact, smokers usually need several attempts before they are able to quit for good.

Lack of success is often related to the onset of withdrawal symptoms. By reducing these symptoms with the use of nicotine replacement therapy, smokers who want to quit have a better chance of being successful.

For smokers, nicotine blood levels will vary, depending on individual smoking patterns such as the time between cigarettes, how deeply the person inhales, the number of cigarettes smoked per day, and the brand smoked. Smoking delivers nicotine to the bloodstream very quickly - within a few seconds. Nicotine replacements generally work more slowly, and the amount of nicotine in the bloodstream is less than that from smoking.

Getting the Most from Nicotine Replacement

Nicotine replacement therapy only deals with the physical aspects of addiction. It is not intended to be the only method used to help you quit smoking. It should be combined with other smoking cessation methods that address the psychological component of smoking, such as a stop smoking program. Studies have shown that an approach - pairing nicotine replacement with a program that helps to change behavior - can double your chances of successfully quitting.

The US Agency for Healthcare Research and Quality (AHRQ) Clinical Practice Guideline on Smoking Cessation recommends nicotine replacement therapy for all smokers except pregnant women and people with heart or circulatory diseases. If a health care provider suggests nicotine replacement for people in these groups, the benefits of smoking cessation must outweigh the potential health risk.

The most effective time to start nicotine replacement is at the beginning of an attempt to quit. Often smokers first try to quit on their own, then decide to try nicotine replacement. Nicotine replacement therapy should not be used if you plan to continue to smoke or use another tobacco product. The combined dose of nicotine could be dangerous to your health.

Smokers who are pregnant or have heart disease should consult with their doctor before using over the counter nicotine replacement.

Types of Nicotine Substitutes

Nicotine patches (transdermal nicotine systems): Patches provide a measured dose of nicotine through the skin. As the nicotine doses are lowered by switching patches over a course of weeks, the tobacco user is weaned off nicotine. 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.

• The 16-hour patch works well for light-to-average tobacco users. It is less likely to cause side effects like skin irritation, racing heartbeat, sleep problems, and headache. But it does not deliver nicotine during the night, so it is not helpful for early morning withdrawal symptoms.
• The 24-hour patch provides a steady dose of nicotine, avoiding peaks and troughs. It helps with early morning withdrawal. However, there may be more side effects such as disrupted sleep patterns and skin irritation.

Depending on body size, most tobacco users should start using a full-strength patch (15-22 mg of nicotine) daily for 4 weeks, and then use a weaker patch (5-14 mg of nicotine) for another 4 weeks. The patch should be applied in the morning to a clean, dry area of the skin without much hair. It should be placed below the neck and above the waist - for example, on the arm. The FDA recommends using the patch for 3 to 5 months. However, some studies have shown that using it for 8 weeks or less is just as effective as using it for longer.

Side effects of the patch are related to:

• the dose of nicotine
• the brand of patch
• your individual skin characteristics
• how long you use the patch
• how it is applied

Some possible side effects of nicotine replacement include:

• skin irritation - redness and itching
• dizziness
• racing heartbeat
• sleep problems
• headache
• nausea
• vomiting
• muscle aches and stiffness

What to do about side effects:

• Try a different brand of patch if skin irritation occurs.
• Reduce the amount of nicotine by using a lower dose patch.
• Sleep problems may be temporary and pass within 3 or 4 days. If not, try switching to a 16-hour patch.
• Stop using the patch and try a different form of nicotine replacement.

Nicotine gum (nicotine polacrilex): Nicotine gum is a fast-acting form of replacement that acts through the mucous membrane of the mouth. It can be bought over-the-counter without a prescription. It comes in 2 mg and 4 mg strengths.

For best results, follow the instructions of the package insert. Chew the gum slowly until you note a peppery taste. Then, "park" it against the cheek, chewing it and parking it off and on for about 20 to 30 minutes. Food and drink can affect how well the nicotine is absorbed. You should avoid acidic foods and drinks such as coffee, juices, and soft drinks for at least 15 minutes before and during gum use.

If you smoke a pack or more per day, smoke within 30 minutes of rising, or have trouble not smoking in restricted areas, you may need to start with the higher dose (4 mg). No more than 20 pieces should be used in one day. Nicotine gum is usually recommended for 1 to 3 months, with the maximum being 6 months. Tapering the amount of gum chewed may help you stop using it.

If you have sensitive skin, you may prefer the gum to the patch. Another advantage of nicotine gum is that it allows you to control the nicotine doses. The gum can be chewed as needed or on a fixed schedule during the day. The most recent data has shown that scheduled dosing is more effective. A schedule of 1 to 2 pieces per hour is common. On the other hand, with an as-needed schedule, you can chew more nicotine during a craving.

Some possible side effects of the gum:

• bad taste
• throat irritation
• mouth ulcers
• hiccups
• nausea
• jaw discomfort
• racing heartbeat

Symptoms related to the stomach and jaw are usually caused by improper use of the gum, such as swallowing nicotine or chewing too rapidly.

Long-term dependence is one possible disadvantage of nicotine gum. In fact, research has shown that 15% to 20% of gum users who successfully quit smoking continue using the gum for a year or longer. Although the maximum recommended length of use is 6 months, continuing to use the gum is likely to be safer than going back to smoking. But since there is little research on the health effects of long-term nicotine gum use, most health care providers still recommend limiting its use to 6 months.

Combination patch and gum: Using the nicotine patch and nicotine gum together is another method of nicotine replacement therapy. It has not been widely researched, but the few available studies look promising. Smokers in most of these studies use the nicotine patches routinely (over 24 hours) and the nicotine gum as a "rescue use" up to 4 pieces a day. It is hoped that this type of combination use will help more people stop smoking and keep them from smoking longer. One advantage to the combined treatment is that the nicotine replacement patch delivers nicotine slowly while the gum works faster and helps reduce withdrawal symptoms. This combination has not yet been approved by the US Food and Drug Administration (FDA).

Nicotine nasal spray: The nasal spray delivers nicotine quickly to the bloodstream as it is absorbed through the nose. It is available only by prescription.

The nasal spray immediately relieves withdrawal symptoms and offers you a sense of control over nicotine cravings. Because it is easy to use, smokers report great satisfaction. However, the Food and Drug Administration cautions that since this product contains nicotine, it can be addictive. It recommends the spray be prescribed for 3-month periods and should not be used for longer than 6 months.

The most common side effects last about 1 to 2 weeks and can include the following:

• nasal irritation
• runny nose
• watery eyes
• sneezing
• throat irritation
• coughing

There is also the danger of using more than is needed. If you have asthma, allergies, nasal polyps, or sinus problems, your doctor may suggest another form of nicotine replacement.

Nicotine inhalers: Introduced in 1998, inhalers are available only by prescription. The nicotine inhaler is a plastic tube with a nicotine cartridge inside. When you puff on the inhaler, the cartridge provides a nicotine vapor. Unlike other inhalers, which deliver most of the medication to the lungs, the nicotine inhaler delivers most of the nicotine vapor to the mouth. Behaviorally, nicotine inhalers are the closest thing to smoking a cigarette, which some smokers find helpful.

The most common side effects, especially when first using the inhaler, include:

• coughing
• throat irritation
• upset stomach

At this time, inhalers are the most expensive of the forms of NRT available.

Nicotine lozenges: These are the newest form of NRT on the market. After undergoing the appropriate testing, the FDA recently approved the first nicotine-containing lozenge as an over-the-counter aid in smoking cessation. As with nicotine gum, the Commit TM lozenge is available in two strengths: 2 mg and 4 mg. Smokers determine which dose is appropriate based on how long after waking up they normally have their first cigarette.

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 3 weeks, and finally, one lozenge every 4-8 hours for 3 weeks. In addition, the manufacturer recommends the following:

• Stop all tobacco use when beginning therapy with the lozenge.
• Do not eat or drink for 15 minutes before using the lozenge. (Some beverages can reduce the effectiveness of the lozenge).
• Suck on the lozenge until it dissolves. Do not bite or chew it like a hard candy, and do not swallow it.
• Stop using the lozenge after 12 weeks. If you still feel you need to use the lozenge, talk to your doctor.
• Do not use the lozenge if you continue to smoke, chew tobacco, use snuff or any other product containing nicotine (e.g., nicotine patch or gum).

Possible side effects of the nicotine lozenge include:

• insomnia (trouble sleeping)
• nausea
• hiccups
• coughing
• heartburn
• headache
• flatulence (gas)

Substances Not Reviewed or Approved by the FDA

Tobacco lozenges: Lozenges containing tobacco, such as Ariva TM, are being marketed as an alternative way for smokers to get nicotine in places where smoking is not permitted, rather than as a tobacco cessation aid. The FDA has ruled that these are a type of smokeless tobacco, not a smoking cessation aid; therefore, the FDA does not have authority over them. There is no evidence that these lozenges can help a person quit smoking.

Nicotine lollipops and lip balms: In the past, some pharmacies throughout the United States made a product called the "nicotine lollipop". These lollipops often contained a product called nicotine salicylate with a sugar sweetener. Nicotine salicylate is not approved for pharmacy use by the FDA. In April 2002, the FDA warned 3 pharmacies to stop selling nicotine lollipops and lip balm on the Internet and called the products "illegal". The FDA also said "the candy-like products present a risk of accidental use by children".

Other similar tobacco cessation products may not use nicotine salicylate, and therefore may be legal. However, they still pose a risk for children if they are not sufficiently labeled and stored safely.

Which Type of Nicotine Replacement Is Right for You?

When choosing which type of nicotine replacement you will use, think about which method will best fit your lifestyle and pattern of smoking. Do you want/need something to chew or occupy your hands? Are you looking for once-a-day convenience?

Some important points to consider:

• Nicotine gums, lozenges, and inhalers are oral substitutes that allow you to control your dosage to help keep cravings at bay.
• Nicotine nasal spray works very quickly when you need it.
• Nicotine inhalers allow you to mimic the use of cigarettes by puffing and holding the inhaler.
• Nicotine patches are convenient and only have to be applied once a day.
• Both inhalers and nasal sprays require a doctor's prescription.
• Some people may not be able to use patches, inhalers, or nasal sprays due to allergies or other conditions.

Other Quitting Tools (Medication)

Other tools, used alone or in combination with nicotine replacement therapy, may improve your chances of quitting.

Zyban (bupropion) is a prescription antidepressant in an extended-release form that reduces symptoms of nicotine withdrawal. This drug affects chemicals in the brain that are related to nicotine craving. It can be used alone or together with nicotine replacement.

In one study, Zyban helped 49% of smokers quit for at least a month. In the same study, 36% of nicotine patch users were able to quit for a month. When both methods were used, 58% of smokers were able to remain smoke free for over a month.

This medication should not be taken if you have a history of seizures, anorexia, heavy alcohol use, or head trauma.

Quitlines - Telephone-based Help to Stop Smoking

More than 30 states run some type of free telephone "Quitline," which links callers with trained counselors. These specialists help plan a quit method that fits each person's unique pattern of tobacco use. People who use telephone counseling stop tobacco use at twice the rate of those who don't get this type of help. With guidance from a counselor, quitters can avoid common mistakes that may hurt a quit attempt.

Telephone counseling is also more convenient for many people. It doesn't require transportation or childcare and it's available nights and weekends. Counselors may recommend a combination of methods including medicines, local classes, self-help brochures, and/or a network of family and friends. Tobacco users can get help finding a Quitline in their area by calling the ACS at 1-800-ACS-2345.

Support of Family, Friends, and Quit Programs

Many former smokers say a support network of family and friends was very important during their quit attempt. Other people who may offer support and encouragement are coworkers, your family doctor, and members of support groups for quitters. You can check with your employer, health insurance company, or local hospital to find support groups; or call the ACS at 1-800-ACS-2345.

Other Tools

Hypnosis might be useful for some people. Ask your doctor if he or she can recommend a good hypnotist if you are interested in this.

Acupuncture has been used for quitting tobacco, but as of yet there is no strong evidence to support its effectiveness. For a list of local physician acupuncturists, contact the American Academy of Medical Acupuncture at 1-800-521-2262.

Filters that reduce tar and nicotine in cigarettes are generally not effective since studies show that smokers who use filters actually tend to smoke more.

Smoking deterrents such as over-the-counter products that change the taste of tobacco, "stop smoking diets" that curb nicotine cravings, and combinations of vitamins have little scientific evidence to support their claims.

A Word About Success Rates

Before you sign up for a stop smoking class or program, you may wonder what its success rate is. That's a hard question to answer for several reasons. First, not all programs define success in the same way. Does success mean that a person is not smoking at the end of the program? After 3 months, or 6 months, or 1 year? If a program you're considering claims a certain success rate, ask for more details on how success is defined and what kind of follow-up is done to verify the rate.

Several articles in medical journals have reported that between 1/4 and 1/3 of smokers who use nicotine replacement or bupropion (Zyban) can remain smoke-free for over 6 months. There is early evidence that combining nicotine replacement therapy with bupropion may be more effective than either one alone. About 5% to 16% of people are able to quit smoking for at least 6 months without any medicine to help with withdrawal.

The truth is, quit smoking programs, like other programs that treat addictions, often have a fairly low success rate. But that does not mean they are not worthwhile or that you should be discouraged. Your own success in quitting is what really counts, and that is under your control. p>Behavioral and supportive therapies increase success rates. Check the package insert of nicotine replacement products to see if the manufacturer provides free telephone-based counseling.