This treatment reduces dependency on nicotine by delivering it through less harmful methods, that is, through the skin in the transdermal method (nicotine patch) or through the oral or nasal tissues (nicotine gum, inhalers, and nasal sprays).
Nicotine patches (Nicoderm CQ®, Nicotrol®, and generic) are available over-the-counter. All patches are applied and worn in the same manner. At the start of each day of the treatment period, the smoker places a new patch on relatively hairless skin somewhere between the neck and waist.
Nicoderm CQ® is usually worn for 6 weeks for 16 or 24 hours a day at a dosage of 21 mg, then for 2 weeks at a dosage of 14 mg, then for 2 additional weeks at a dosage of 7 mg. Nicotrol® is worn for 6 weeks for 16 hours a day at a dosage of 15 mg.
People who have serious arrhythmia, serious or worsening angina pectoris, those with high blood pressure, depression, or asthma, or those who have recently suffered a heart attack should consult their health care provider before using a patch.
The most common side effect is a local skin reaction, experienced by 50% of patch users. This reaction is usually mild and easily treated by hydrocortisone or triamcinolone cream, or by rotating patch sites. Another common side effect is insomnia. In that case, the 24-hour patch may be removed before bedtime, or a change may be made to the 16-hour patch.
Nicotine gum (Nicorette® or Nicorrett Mint®) is available over-the-counter. The gum is chewed until a "peppermint" taste emerges and then held between the cheek and gums to allow the nicotine to be absorbed. It is alternately chewed and held between the cheek and gums for about 30 minutes until the taste dissipates.
Nicotine gum is available in 2 mg and 4 mg per piece doses. The 2 mg per piece gum is recommended for those who smoke less than 25 cigarettes per day and the 4 mg per piece gum is recommended for those who smoke more than 25 cigarettes per day. The gum is usually used for up to 12 weeks with no more than 24 pieces per day.
Nicotine gum therapy often fails if people chew too few pieces per day or do not continue chewing for a sufficient number of weeks. The U.S. Public Health Service recommends a fixed schedule of a minimum of one piece every 1–2 hours for at least 1–3 months.
Common side effects include soreness of the mouth, hiccups, indigestion, and jaw ache. Modifying the chewing technique can usually alleviate these effects.
Nicotine nasal spray (Nicotrol NS®) is available by prescription only. It is administered in one 0.5 mg dose to each nostril. Initially, the spray is administered in 1–2 doses per hour, and then increased as needed to relieve symptoms. A minimum of 8 doses per day and a maximum of 40 doses per day is recommended. Treatment usually lasts 3–6 months.
Ninety-four percent of people using nicotine nasal spray experience moderate to severe nasal irritation in the first 2 days of use. Eighty-one percent experience nasal irritation after 3 weeks, although the effect is much less severe.
Some users develop a dependency to nicotine nasal spray. About 15–20% of users reported using the spray for 3–6 months longer than recommended, and at a higher dose than recommended. Nicotine nasal sprays cannot be used in combination with other NRT (such as a patch).
Psychotropic Agents to Quit Smoking
Psychotropic agents (commonly used to treat depression) are sometimes used to treat nicotine addiction because they regulate receptors in the brain that are affected by nicotine.
Bupropion (Zyban®) is only available by prescription. Unlike nicotine replacement therapies, which typically begin on the smoker's quitting day, smokers begin taking bupropion 1–2 weeks before they quit smoking. The initial dose is 150 mg in the morning for 3 days, and then 150 mg twice a day, continuing for 7–12 weeks.
Bupropion should not be used by anyone with a history of a seizure or eating disorder. Patients who are using another form of bupropion or who have used a monoamine oxidase inhibitor (MAOI) in the past 14 days also should not use bupropion. People taking bupropion should limit alcohol consumption.
Side effects may include hypertension, tremor, insomnia, and dry mouth. Zyban is not recommended for women who are pregnant or nursing.
Varenicline (Chantix®) is a non-nicotine medication that is available by prescription for smoking cessation. This drug attaches to nicotine receptors in the brain, helps block nicotine from reaching these receptors, and may reduce the release of dopamine triggered by nicotine. Varenicline also is taken for 1 week before the smoker's quitting day to allow the medicine to build up in the body.
Side effects may include nausea and vomiting, constipation, and difficulty sleeping. In some cases, a serious reaction can occur. Signs of a severe reaction include swelling of the face, mouth, and throat and redness, swelling, and peeling of the skin.
In 2009, the U.S. Food and Drug Administration (FDA) issued a black box warning for the smoking cessation drugs bupropion and varenicline. According to the FDA, these medications carry an increased risk for mental health side effects, such as depression, behavioral changes (e.g., hostility, irritability), and suicidal thoughts. Patients who use these drugs to stop smoking should be closely monitored while taking them and after the medication is discontinued.
In July 2011, the FDA updated labeling for Chantix to include new information about the effectiveness of the drug for people with stable heart disease and mild or moderate COPD who are trying to quit smoking. Studies have shown that Chantix is effective in these patients—in some cases, almost doubling the chance of quitting for at least one year. These same studies shown that a slight increased risk for adverse cardiovascular events is possible in people with heart disease who use Chantix.
Clonidine, a commonly used antihypertensive, is available only by prescription in oral and transdermal form. It has not been approved by the FDA for the treatment of smoking cessation and is used only as a second-line therapy if first-line therapies have been unsuccessful.
Clonidine doses vary from 0.15–0.75 mg per day (oral form) to 0.10–0.20 mg per day (transdermal form) and the duration of treatment varies from 3–10 weeks. Treatment begins up to 3 days before quitting or on the quit date. The patient puts a new patch (transdermal form) on relatively hairless skin between the neck and waist each week.
While clonidine is effective, its side effects limit its usefulness. The most common side effects include dry mouth, drowsiness, dizziness, sedation, and constipation. Because clonidine lowers blood pressure in most patients, any reduction in dosage must be done gradually over 2-4 days to reduce the risk for rebound hypertension, marked by a rapid increase in blood pressure, agitation, confusion, and tremor.
Nortriptyline (Nortriptyline HCl) is only available by prescription. This antidepressant has not been approved by the FDA for smoking cessation and is recommended only if first-line therapies have been unsuccessful.
Patients begin taking nortriptyline 10–28 days before quitting. It is taken orally in doses of 25 mg per day, increasing to 75–100 mg per day for 12 weeks. Side effects include sedation, dry mouth, blurred vision, urinary retention, lightheadedness, shaky hands, and constipation. Overdose with nortriptyline can have cardiotoxic effects and it should be used with extreme caution.
While drug treatments (e.g., nicotine patch, bupropion) can double women's chances for success when attempting to quit smoking, a combination of drug and psychotherapy can further increase the chance for success.
Cognitive and behavioral therapies are often practiced together for maximum effect in helping the smoker alter thinking and behavior. In both approaches, the smoker is encouraged to take an active role in analyzing and changing her thinking and behavior.
Cognitive Therapy to Quit Smoking
In cognitive therapy, thinking patterns that lead to smoking are identified and then altered for more healthy outcomes. For instance, someone who thinks "Smoking relieves my stress" will learn to think "I can relieve my stress another way." The therapist also gives practical instruction in biofeedback and other stress-reduction techniques.
Behavioral Therapy to Quit Smoking
Behavioral therapy helps people weaken the link between the stimuli that trigger habitual responses by prescribing specific acts or behaviors to replace smoking. For instance, a smoker may replace smoking with manual activities such as cooking or gardening.
Quit Smoking Support Groups
Support groups often incorporate elements of cognitive and behavior therapy, and have the additional advantage of providing a social network that encourages the smoker to quit. Women appear to benefit from participating in a support group and are more likely than men to join a group.