Wearing the patch prior to quitting may help

If you buy a box of nicotine patches, you will notice that the instructions for use and warnings advise against wearing the patch while taking nicotine from any other source. Many smokers interpret this as implying that something terrible will happen if they kept the patch on while smoking, and consequently when they have a lapse cigarette then often decide to take the patch off (and so obey the instructions on the box).

However, numerous studies have shown that nothing terrible happens when you smoke while wearing the patch. 15 years ago I published a study in which 30 smokers smoked normally for 2 weeks, and wore full strength nicotine patches for one of those weeks and placebo patches for the other. The smokers generally couldn’t tell which week was the week with the nicotine patches and the single participant who vomited did so while wearing placebo patches! So it appears to be very unlikely for smokers to experience adverse events caused by wearing the patch while smoking.

However, some recent studies have actually suggested that wearing the patch for a few weeks prior to the target quit date may actually increase the chances of a successful quit. One such study was carried out by Dr Schuurmans and colleagues in South Africa. They found that people who wore nicotine patches for two weeks prior to their quit day had better long term quit rates than smokers who wore placebo patches for two weeks prior to their quit date (22% vs 12% quit, 6 months later).

Interestingly, studies of the use of other forms of nicotine replacement therapy by smokers not intending to quit have also found that not only does the NRT help them to reduce their cigarette consumption, but that a significant proportion of them go on and quit completely. One such study was carried out by Dr Batra and colleagues in Germany. They recruited over 300 smokers who were interested in cutting down but not quitting. They were provided with either 4mg nicotine gum or placebo gum for a year. As well as helping with smoking reduction, the group receiving the nicotine gum had significantly more people who were quit 13 months later (12% versus 5%).

We are not clear on the mechanism whereby combining NRT with smoking prior to quitting may help subsequent cessation. It may simply be that it loosens the associations between smoking and reinforcement (by providing nicotine separately from smoking). Just to be clear, the use of NRT prior to the quit date is not yet normal practice, and may never become so. My current practice is to advise patients using the patch to put their first patch on the morning of their quit day and not before (as suggested on the box). However, as more evidence is gathered on the safety and effectiveness of NRT pre-treatment, I may have to reconsider.

Labels: cessation, nicotine, pre-treatment, replacement, Smoking

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Advice on using over-the-counter nicotine replacement therapy.

Surveys have shown that many smokers (incorrectly) do not believe that nicotine replacement therapy helps smokers to quit. Many also believe NRT can cause cancer (again incorrectly). Unfortunately the labeling on the NRT product packaging also uses very cautious language that reinforces the idea that NRT can be dangerous. For examples, the long list of precautions regarding co-occurring medical problems, the advice to use low doses unless you are a heavy smoker, and the advice against using the NRT if you smoke or use another NRT, all feed the perception that NRT is dangerous and should be avoided if at all possible.

Partly because of these miscommunications to the public, only a fraction of those trying to quit smoking use an effective smoking cessation aid and even fewer use it in an optimal manner for smoking cessation. In order to help improve this situation, Professor Lynn Kozlowski (University of Buffalo) and a group of experts in smoking cessation have produced a paper discussing these issues, and (importantly) providing a consensus statement on the most effective way to use NRT. The summarized version of the agreed-upon advice to consumers is provided below:



1. NRT is one good tool to help you quit smoking. But NRT can’t do all the work for you—you have to help—and it is not the only tool to help you stop smoking.


2. Don’t worry about the safety of using NRT to stop smoking: NRT is a safe alternative to cigarettes for smokers.


3. Do be cautious about using NRT while pregnant.


4. NRT is less addictive than cigarettes and it is not creating a new addiction


5. Stop using NRT only when you feel very sure you can stay off cigarettes.


6. If the amounts of NRT you are taking do not help you stop smoking, talk with your health care provider about using (1) more NRT, (2) more than one type of NRT at the same time, (3) other smoking cessation medicines at the same time, or (4) telephone or in person advice on quitting tips.


7. If NRT helps you stop smoking, but you go back to smoking when you stop using NRT, you should seriously think about using NRT again the next time you try to stop smoking.


8. Make sure you are using the gum or lozenge in the best way:
o Chew the gum slowly – fast chewing doesn’t allow the nicotine to be absorbed from the lining of the mouth and can cause nausea.
o Don’t drink anything for 15 minutes before and nothing while you are using nicotine gum or the lozenge so your mouth can absorb the nicotine.
o Make sure you get the right amount of nicotine – people who smoke more than 10 cigarettes per day should use a 4mg piece of gum or lozenge.


9. Make sure you are using the patch in the best way:
o If you can’t stop having a few cigarettes while using the patch, it is best to keep the patch on. Don’t let a few slips with cigarettes stop you from using the patch to quit smoking.
o You may need to add nicotine gum or lozenges to help get over the hump or you may need to use more than one patch at a time. Talk to your healthcare provider about this.


10. If the price of NRT is a concern, try to find “store brand” (generic) NRT products which are often cheaper than the brand name products.

11. Do whatever it takes to get the job done—it is not a weakness to use medicine to stop smoking.

Adapted from: Kozlowski LT, .Giovino GA, Edwards B, DiFranza J, Foulds J, Hurt R, Niaura R, Sachs DPL., Selby P, Dollar KM., Bowen D Cummings KM, Counts M, Fox B, Sweanor D, Ahern F. Advice on using over-the-counter nicotine replacement therapy- patch, gum, or lozenge- to quit smoking. Addictive Behaviors (in press).

Some of these pieces of advice contradict some of the advice given on the product packaging (e.g. suggestion to combine NRTs and to continue use until confident of quitting). However, this advice is based on the latest research evidence and the clinical expertise of 16 experts on tobacco treatment.

You can read the full paper and a Spanish translation of the key points at:
http://proyectovidanofume.org/publication.htm

Labels: aid, cessation, nicotine, nicotine addiction cigarette smoking tobacco, replacement, therapy

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Is nicotine replacement therapy effective in the “real world”?

Over a hundred double-blind randomized placebo-controlled trials have evaluated the efficacy of nicotine replacement therapy for smoking cessation, and the results are very clear: use of NRT almost doubles the smokers’ chances of successfully quitting. Five years ago, a paper published in the Journal of the American Medical Association by Professor John Pierce and colleagues claimed that since becoming available over-the-counter, NRT was no longer effective. This study was based on retrospective recall of quit attempts by respondents to a large survey in California. Many researchers questioned the validity of the findings, partly based on evidence that smokers are more likely to forget unaided failed quit attempts, and partly because smokers who choose to use NRT tend to be more addicted than those choosing to quit on their own, and the Pierce study was not able to adequately measure this.

Since then, a number of studies have been published that shed more light on this issue. A more recent study by the same research group found that use of a pharmacological aid (NRT or bupropion) is more effective than no aid in households with either no other smokers or a smoke-free policy. This result was an interesting demonstration of the interaction between effects of a medication and the environment in which it is used. It also suggests that effectiveness of NRT has little to do with whether it is prescribed by a doctor or purchased over the counter. However, this study still relied on retrospective recall and so some doubts about recall accuracy remain.

Further light was shed on this issue in a study by Miller and colleagues published in the Lancet in 2005. They reported on a large scale distribution of free nicotine patches (via a telephone quitline) to over 34,000 people in New York City. Six months later they followed up a randomly selected sample of participants, and also a sample of people who called the quitline but did not receive patches due to mailing errors. They found that 33% of those receiving patches had quit 6 months later, as compared with only 6% among those not receiving them. This suggests that nicotine patches are effective when used along with very low intensity support.

Very recently, Professor Robert West and Xiaolei Zhou have reported in the journal, Thorax, the results of a multinational prospective study of over 3,605 smokers attempting to quit. This study found that those using NRT were about twice as likely (8% vs 4%) to remain continuously abstinent six months later. This study, like the New York City patch study, supports the findings from randomized clinical trials and demonstrates that smokers making a self-initiated quit attempt without additional behavioral support are twice as likely to remain abstinent for at least six months if they use NRT as compared with trying without NRT. Nicotine replacement therapy is therefore an effective aid to smoking cessation in the “real world”.

Labels: cessation, nicotine, nicotine addiction cigarette smoking tobacco, replacement, therapy

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Which nicotine replacement therapy?

Nicotine replacement therapy (NRT) is the name given to FDA-approved medicines containing nicotine that are used to reduce nicotine withdrawal symptoms and cravings and to help smokers quit. Currently there are 5 main types: patch, gum, lozenge, nasal spray and inhaler. These latter two (nasal spray and inhaler) are only available via prescription in the United States, although they are available over-the-counter in many other countries (e.g. UK).

Each type of NRT has its own advantages and disadvantages. The patch is by far the most commonly used NRT, largely because it is the easiest to use, requiring only a single patch application per day. Another advantage of the patch is that its side effects are usually mild – primarily mild skin irritation and itching. The main disadvantage is that there is nothing one can do with the patch to increase the dose when you feel the need for more nicotine.

The gum and the lozenge are broadly similar in terms of dose (each available in 2mg and 4mg formats) and route of administration. The main challenge facing the gum chewer is to adopt a “chew and park” style, such that you chew the gum a few times to release a peppery taste (nicotine) and then park it in the side of your mouth for a few minutes before chewing again. The labeling on the gum suggests that people who smoke less than 25 cigarettes per day should use 2mg (rather than 4mg) and the labeling on the lozenge states that those who don’t smoke within 30 minutes of waking in the morning should use the 2mg lozenge. In practice many clinicians have learned that this labeling (especially the gum) is a recipe for under-dosing and advise all but the lightest smokers to use the 4mg formulation of each product. To get a real benefit from these products you need to use enough. Most users only take 3 or 4 per day in response to cravings. You can get a far greater benefit by taking one per hour (to prevent cravings and withdrawal symptoms) plus another whenever you have a breakthrough craving.

I described the nicotine nasal spray in some detail a few days ago. It appears to be particularly helpful for heavy addicted smokers who are willing to persevere despite the initial nasal irritation. Make sure you have some Kleenex handy when you first try the spray. The initial doses sting and will make you sneeze. But, just as with smoking, you will get used to it within a few days, and within a week will probably like it!

The inhaler‘s main advantage is that it enables the smoker to continue with a similar hand/mouth habit, but it helps to gradually wean them off nicotine. The main thing to note is that one puff on a cigarette delivers a similar amount of nicotine to ten puffs on the inhaler. This means that in order to obtain a therapeutic dose, the ex-smoker has to be puffing on the nicotine inhaler almost all the time. We recommend puffing on the inhaler for 20 minutes out of ever waking hour. Again, people who get into that regular use habit early on tend to do very well with the inhaler.

Some years ago Professor Peter Hajek and colleagues at the University of London conducted a randomized trial comparing the nicotine patch, gum, nasal spray and inhaler. In practice they all had similar quit rates (around 20-25% complete abstinence 3 months later), although women did better on the inhaler than the gum and men were the opposite. Prior to their quit attempt, participants were shown videos describing each NRT and were then allowed to rate their preferences. They were each then randomly allocated to one product. This meant that some people were allocated the product that was their first preference, whereas most were not. However, at the end of the study the smoking cessation outcomes were similar for those receiving their preferred NRT versus those being randomly allocated to a less preferred NRT. Also, people came to prefer the product they were given after they had used it for a week.

One final thing to consider is that the products differ in the risk of inducing dependence. It is extremely rare for someone to have any difficulty coming off the patch (which typically have a built-in reduction plan, involving using smaller sized patches over 4 weeks). However, some people (about 5-10%) find themselves using the gum, inhaler or lozenge long term (i.e. over 3 months and possibly continuing for years). The nicotine nasal spray has the highest dependence potential, with around 10-15% of those who use it continuing use after 3 months. The risk of becoming dependent is related to the speed of nicotine delivery from the product (spray fastest, but still slower and lower dose than a cigarette, whereas the patch delivers nicotine very slowly). It also seems to be related to how addicted the person was to their cigarettes. Thus people who smoked over a pack a day and smoke within 30 minutes of waking in the morning (or wake at night to smoke) are more likely to become a long term user of their NRT product. However, in the placebo-controlled trials these were precisely the people who were much less likely to succeed in quitting if they received the placebo. The thing to remember here is that it is much better to be a long term user of an NRT product delivering only nicotine, than a continuing user of a product that delivers a higher dose of nicotine plus 4000 other toxic chemicals (i.e. a cigarette).

Recently a group of experts in the treatment of tobacco addiction got together to produce a consensus statement guiding consumers on the most effective ways to use NRT to help them quit smoking. You can find a copy of the paper and the summary (in both English and Spanish) at: http://proyectovidanofume.org/publication.htm

Labels: addiction, cigarette, nicotine, NRT, replacement, Smoking, therapy, tobacco

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