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:
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About the Author

MA, MAppSci, PhD

Dr. Jonathan Foulds is an expert in the field of tobacco addiction.