People who smoke cigarettes or use other forms of tobacco often have a difficult time when they try to stop. The difficulty is partly psychological; they get in the habit of using tobacco at certain times of day or while they are doing certain things, such as having a cup of coffee or reading the newspaper. But the habit is also hard to break for physical reasons. Tobacco contains nicotine, a drug that is as addictive as cocaine or heroin. Of those who have ever tried even a single cigarette, about a third will become nicotine-dependent. A person who is addicted to nicotine has withdrawal symptoms, such as irritability, anxiety, difficulty concentrating, and craving for tobacco when he or she stops using tobacco.
Some people can stop smoking through willpower alone, but most do better if they have support from friends, family, a physician or pharmacist, or a formal stop-smoking program. Heavy tobacco users may find that smoking cessation products also help by easing their withdrawal symptoms. Most smoking cessation products contain nicotine, but the nicotine is delivered in small, steady doses spread out over many hours. In contrast, when a person inhales a cigarette, nicotine enters the lungs and then travels to the brain within seconds, delivering the "rush" that smokers come to crave. Another difference is that smoking cessation products do not contain the tar, carbon monoxide, and other toxins that make cigarettes so harmful to people's health. According to one Canadian study, tobacco smoke contains over 40 different chemicals known to cause cancer.
The importance of smoking cessation is reflected in legal penalties against the tobacco industry for its longstanding denial of the harm caused by tobacco products. Recent legal findings against the tobacco industry have led to legislation in three states concerning lawsuits against the industry. In Florida, state agencies can sue on behalf of Medicaid recipients for repayment of benefits. Maryland allows the use of statistical analysis in lawsuits against tobacco companies. In Vermont, the state can bring direct lawsuits against tobacco manufacturers to recover Medicaid benefits for tobacco-related illnesses paid after April 1998. Nineteen states (Alabama, Alaska, Connecticut, Florida, Hawaii, Louisiana, Maryland,
Nicotine replacement products
Smoking cessation drugs that contain nicotine are also called nicotine substitution products or nicotine replacement therapy. There are four forms approved by the Food and Drug Administration (FDA) as of 2001— chewing gum, skin patch, nasal spray, and inhaler. The nasal spray and inhaler are available only with a prescription, but the gum and some brands of the patch can be bought over the counter (without a prescription). People who buy the nonprescription products should check with a physician before starting to use them. The patches are sold under the brand names Nicotrol, Nicoderm CQ, and Habitrol (prescription only). The gum is sold under the brand name Nicorette. The nasal spray and inhaler are marketed as Nicotrol NS and Nicotrol respectively. The costs of these products are about $30 for a box of 48 pieces of the gum and about $30 per week for the patches.
Another type of smoking cessation drug, bupropion (Zyban), also reduces craving and withdrawal symptoms, although it is not a nicotine replacement product. Bupropion is an antidepressant medication that is thought to help people stop smoking by mimicking some of the effects of tobacco on brain tissue. Bupropion can be used together with nicotine replacement products; several studies indicate that the combination helps more smokers quit than either method by itself.
Other approaches that have been used to help smokers quit include hypnosis and acupuncture. The evidence for the usefulness of hypnosis is largely anecdotal; it appears to be most helpful when used in combination with nicotine replacement products or bupropion. Although acupuncture has been used in Western countries since the 1970s to help people quit smoking, it does not appear to be particularly effective in this regard. A British study that was published in 1999 found that smokers who received acupuncture did not have a higher quit rate than those who received only sham acupuncture.
The recommended dosage of nicotine replacement products depends on the method of administration. Each form of this medicine comes with detailed instructions for its use. Following directions exactly is very important. For example, nicotine gum should not be chewed like regular chewing gum. It must be chewed very slowly until it has a slight taste or causes a slight tingling sensation in the mouth; then "parked" between the cheek and gum until the taste and tingling goes away; then chewed and parked in the same way for about 30 minutes. Nicotine patches and other products also must be used correctly to be effective. Some patches are meant to be worn only during the day and removed at night; others are worn 24 hours a day.
Smokers who are heavily dependent on nicotine may want to ask their doctors about using a combination of nicotine replacement products. Studies done between 1995 and 2000 indicate that combining the transdermal patch with either the gum or the nasal spray helps more smokers quit than any of the three products by themselves. It is thought that the higher success rate is due to the different rates of speed at which these products deliver nicotine to the body. The nasal spray delivers nicotine very rapidly, and can be used to relieve intense cravings at times of the day when the smoker is accustomed to having a cigarette, while the patch delivers a smaller dosage of nicotine to the body at a steadier rate.
Seeing a physician regularly while using smoking cessation drugs is important. The physician will check to make sure the medicine is working as it should and will watch for unwanted side effects.
Nicotine by itself is a poisonous substance. Do not smoke during treatment with smoking cessation drugs that contain nicotine, as the combination could lead to nicotine overdose. For the same reason, do not use more than one type of smoking cessation product at a time, and never use more than the recommended amount of medicine. Signs of nicotine overdose include:
- severe pain in the stomach or abdomen
- severe diarrhea
- severe dizziness
- convulsions (seizures)
- low blood pressure
- fast, weak, or irregular heartbeat
- hearing or vision problems
- severe breathing problems
- severe watering of the mouth or drooling
- cold sweat
- severe headache
- severe weakness
Keep these drugs, including thrown-away patches and gum—out of the reach of children and pets. Even a small amount of nicotine can seriously harm a child or animal.
Nicotine in any form should not be used during pregnancy, as it may harm the fetus or cause miscarriage. Women who may become pregnant should use effective birth control while taking smoking cessation drugs. Women who become pregnant while taking this medicine should stop taking it immediately and check with their physicians.
Nicotine passes into breast milk and may cause problems for nursing babies. Women who are breastfeeding and want to use smoking cessation drugs may need to stop breastfeeding during treatment.
Anyone who has had unusual reactions to nicotine in the past should let his or her physician know before using a smoking cessation drug. The physician should also be told about any allergies to foods, dyes, preservatives, or other substances. People who have had a rash or irritation from adhesive bandages should check with a physician before using a nicotine patch.
Smoking cessation patches, gum, and other products may make certain medical problems worse. Before using a smoking cessation drug, people with any of these medical problems should make sure their physicians are aware of their conditions:
- heart or blood vessel disease
- high blood pressure
- overactive thyroid
- skin rash or irritation
- stomach ulcer
- pheochromocytoma (pcc) (a tumor of the adrenal medulla)
- dental problems or mouth sores
- sore throat
- jaw pain or temporomandibular joint disorder (TMJ)
There are also precautions to take with bupropion and buspirone. Bupropion should not be taken by patients with a history of seizures, high blood pressure, anorexia, or bulimia nervosa. People taking buspirone should be careful about driving or operating heavy machinery until they can tell whether the drug makes them drowsy as a side effect. Although buspirone does not interact with alcohol as intensely as most tranquilizers do, patients should still use alcohol cautiously if they are taking buspirone.
Each type of smoking cessation product may cause minor side effects that usually go away as the body adjusts to the drug. These usually do not need medical attention unless they continue or they interfere with normal activities. For example, nicotine gum may cause belching, jaw aches, or sore mouth or throat. Nicotine patches may cause redness, itching, or burning where the patch is applied. The nasal spray may irritate the nose and sinuses, while the inhaler may cause throat irritation or coughing.
If nicotine gum injures the mouth, teeth, or dental work, check with a physician as soon as possible. Other side effects are possible. Anyone who has unusual symptoms while using smoking cessation drugs should get in touch with his or her physician.
People taking certain drugs may need to change their doses when they stop smoking. Anyone who uses a smoking cessation drug should let the physician know all other medicines he or she is taking and should ask whether the doses need to be changed. Examples of drugs that may be affected when a person stops smoking are:
- airway opening drugs (bronchodilators) such as aminophylline (Somophyllin), oxtriphylline (Choledyl) or theophylline (Somophyllin-T)
- opioid (narcotic) pain relievers such as propoxyphene (Darvon)
- the beta blocker propranolol (Inderal)
Other drugs may also interact with smoking cessation drugs. Be sure to check with a physician or pharmacist before combining smoking cessation drugs with any other prescription or nonprescription (over-the-counter) medicine.
Bupropion should not be used by patients who are also taking monoamine oxidase inhibitor (MAOI) medications. These include such drugs as furazolidone, isocarboxazid, and phenelzine. Bupropion may also interact with phenytoin, carbamazepine, and levodopa. Buspirone also interacts with MAOIs, as well as with trazadone and haloperidol.
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Rebecca J. Frey, PhD
Acupuncture—A Chinese medical practice that treats illness or addictions by the insertion of very thin steel needles at specified points along the body's energy channels.
Nicotine—A colorless, oily chemical found in tobacco that makes people physically dependent on smoking. It is poisonous in large doses.
Withdrawal symptoms—A group of physical or mental symptoms that may occur when a person suddenly stops using a drug on which he or she has become dependent.