A definitive guide on nicotine replacement therapy

stop smoking

Smoking remains one of the leading cause of preventable disease and death in the world. So, quitting smoking is likely one of the best things (maybe the best thing) that someone can do for their health. However, there are many different ways to attempt quitting; some try to go cold-turkey, while others look for any help they can get.

Nicotine patches (and/or other nicotine replacement products) are often the first thing that people will try in order to quit smoking; this article will review this essential tool for smoking cessation.

What forms of nicotine replacement therapy are available?

There are currently multiple forms of nicotine replacement that are available from multiple brands:

  • Nicotine patch
  • Nicotine gum
  • Nicotine lozenge
  • Nicotine spray
  • Nicotine inhaler

Are nicotine patches (and other forms of nicotine replacement) available over-the-counter?

All current forms of nicotine replacement therapy (including patches, gum, lozenges, sprays, or inhalers) are available over-the-counter without a prescription in Canada.

In the United States, it’s a bit more complicated: nicotine patches, gum, and lozenges are available over-the-counter; but nicotine sprays or inhalers require a prescription to access them.

How do nicotine patches work?

In order to explain how nicotine patches work, it might be useful to first explain how smoking works with regard to nicotine.

When you smoke a cigarette, there is a very rapid rise in nicotine levels in the body. However, this rise is short lived and the nicotine levels will then drop quite rapidly. The graph below may help you visualize what I’m describing:

Each cigarette brings a rush of nicotine, followed by a relatively quick crash in nicotine levels

Nicotine patches, on the other hand, release a constant (but relatively small) amount of nicotine through the skin for up to 24 hours. The aim is to ensure that there is always a constant level of nicotine in the body. This achieves 2 goals:

  1. You are preventing nicotine withdrawal by keeping nicotine levels above a certain threshold where withdrawal symptoms would occur
  2. You are avoiding drastic peaks and valleys of nicotine levels in the body (i.e. no big rush from smoking and no big crash afterwards either)

The graph below illustrates the difference in nicotine levels in the body between a nicotine patch (orange line) and smoking cigarettes (grey line):

There are also different strengths of nicotine patches available; this allows you to gradually taper down the amount of nicotine over time (which will further lower your risk of withdrawal symptoms). The 3 different strengths of nicotine patches are:

  • Nicotine 21 mg patch – Also known as “Step 1”
  • Nicotine 14 mg patch – Also known as “Step 2”
  • Nicotine 7 mg patch – Also known as “Step 3”

How do you use nicotine patches?

Before starting the patch, you need to pick an initial dose. This is done by determining how much nicotine you are currently consuming through smoking. One cigarette usually contains around 1 to 2 mg of nicotine. So, to determine which “step” of patch you need to start with, you would calculate the approximate daily total of nicotine ingested.

The approved labeling for the nicotine patches indicate that the initial strength of the patch should be 21 mg for those who smoke more than 10 cigarettes a day, and 14 mg for those who smoke less than 10 cigarettes a day. Once you have used the first dose (or step) of nicotine patches for about 6 weeks, you then go down to the next dose for a few weeks, then to the 3rd (and final) dose for a couple weeks, and then stop.

However, this can sometimes lead to under-dosing of nicotine in people who smoke a lot of cigarettes. If someone smokes 40 cigarettes in 1 day, they are getting between 40 and 80 mg of nicotine; so starting at 21 mg seems like a recipe for failure.

The hospital where I work uses the Ottawa Model for Smoking Cessation. This model has been validated and has been shown to increase the likelihood of successfully quitting. One thing that I particularly like about the model is that they don’t have a maximum dose of 21 mg for nicotine patches. They realize that when patients are smoking they are essentially dosing themselves with nicotine, so we shouldn’t be scared to give them the same amount via nicotine replacement therapy (especially considering we are no longer giving all of the other crap in cigarettes). However, this should only be done under the guidance of a regulated healthcare professional.

So, if you are someone who finds that the 21 mg (step 1) patches aren’t enough, then you should speak to your doctor or pharmacist to set up an individualized treatment plan that is right for you.

Are nicotine patches safe?

Nicotine patches have been used for many years and are considered to be very safe. The potential side effects of nicotine can include*:

  • Gastrointestinal effects* (such as nausea, vomiting, diarrhea, abdominal pain, or hiccups)
  • Headache
  • Sleep disturbances** (such as vivid dreams)
  • Local irritation (i.e. throat irritation from inhalers or sprays, mouth irritation from gum or lozenges, skin irritation from patches)

*Note that GI effects may not be as common in people who have been smoking for a long time, as their body would already be used to the same level of nicotine. GI side effects may be a sign of overshooting with the nicotine replacement dose or using the therapy inappropriately
**A practical tip to manage night-time issues with nicotine patches is to remove them prior to going to bed

Can nicotine replacement therapy cause cancer?

Nicotine on its own is not thought to be carcinogenic. There is no evidence to suggest that nicotine replacement therapy on its own would lead to increased cancer risk. The risk of cancer from cigarettes comes from all of the other ingredients, not from nicotine.

How do the on-demand forms of nicotine replacement (lozenges, gum, inhaler, spray) work?

The on-demand forms of nicotine replacement tend to contain about the same amount of nicotine as one cigarette (which, as I’ve already mentioned above, is around 1 to 2 mg of nicotine). The way they are delivered will vary; this can help you choose which type is best for you. The goal of these methods is to give a faster onset of nicotine activity as-needed when cravings occur.

Nicotine gum

Chewing nicotine gum releases nicotine into the mouth, and it is then absorbed into the body through the mouth (NOT by swallowing it). To choose the dose, refer to the product labeling; usually those who smoke less than a pack a day will use the 2mg dose and those who smoke a pack or more use the 4 mg dose.

The best way to use nicotine gum is to follow these steps when you have a craving:

  • Chew the gum until the taste becomes strong
  • “Park” the gum between your teeth/gums and your cheek (similar to what people do with chewing tobacco)
  • After a few minutes (usually when the taste is gone from your mouth), chew the gum until the taste returns and park it again on the other side of your mouth for a few minutes.
  • Repeat these steps for about 15 to 30 minutes and then spit out the gum.

Note that you shouldn’t chew nicotine gum like you would normal gum, since this will increase the risks of getting GI side effects.

This video may also be helpful:

Video by Nicorette

Nicotine lozenges

Nicotine lozenges are similar to nicotine gum, where the nicotine is absorbed through your mouth. However, you should NOT chew or swallow the lozenge; the best way to use the nicotine lozenge is to:

  • Place the lozenge in your mouth between your teeth/gums and cheek
  • Move it back and forth from one side of your mouth to the other every few minutes
  • Continue until the lozenge has completely dissolved

Nicotine spray

Nicotine sprays will usually give faster results than what you would see from the gum or lozenges. All you have to do is spray it in your mouth, and the nicotine gets absorbed through the mouth. In general this is how to use the spray:

  • Open the spray
  • If it’s the first use, or it’s been a few days, push down to ensure the spray is primed
  • Spray once into the mouth; avoiding the lips or the back of the throat
  • Try NOT to swallow or inhale for a few seconds to allow the nicotine to absorb
  • If after 2 minutes you still have a craving, you can repeat the spray.

With this device it’s much easier to follow how to use it when looking at a video:

Video by Nicorette

Nicotine inhaler

If you are a person who also has a hard time getting rid of the “hand-to-mouth” gesture of smoking, then the nicotine inhaler may be the best option for you. As with all the other forms, the nicotine is absorbed through the mouth; but, the nicotine gets into the mouth by inhaling on the device (because it’s going in the mouth to be absorbed, you don’t need to inhale deeply).

As with the mouth spray, it may be easier to follow visually:

Video by Nicorette

It’s important to note that the inhaler tends to be more expensive than the other forms of nicotine replacement therapy. If you want a low budget alternative to help with keeping your hands busy, consider buying some plastic drinking straws and cutting them into cigarette-sized pieces. Then, simply inhale room air, or chew on them. (Credit: my dad when he quit smoking)

Is it OK to use other forms of nicotine replacement along with nicotine patches?

As I mentioned earlier, we should not be scared to use nicotine replacement in people who have been smoking. Using as-needed forms (such as gum, lozenge, spray, or inhaler) is perfectly fine to deal with occasional cravings that can occur while using the patch.

If you find that you are needing a lot of as-needed nicotine throughout the day while on the patch, then this may be a sign that you aren’t getting enough from the patch at the moment. In this situation, talk with your doctor or pharmacist to see what the best steps to take would be.

How well do nicotine patches work to help you stop smoking?

It’s well established that using nicotine replacement therapy is better than stopping cold-turkey. There are many studies evaluating many different types of nicotine delivery. A recent analysis looking at 133 different studies suggests that nicotine replacement therapy will improve your chances of successfully quitting by around 50 to 60%.

When comparing a single-agent regimen (e.g. only the patch) with a combination regimen (e.g. patch + as-needed nicotine), an analysis of 63 different studies found that people using a combination were a further 25% more likely to successfully quit when compared to those using a single agent.

The Bottom Line

Nicotine replacement therapies can include many different forms of nicotine to help reduce the chances of withdrawal symptoms. They have been shown to significantly increase the chances of successfully quitting, and are also shown to be very safe.

If you are a heavy smoker, the usual dosing may not be enough. Consider speaking with your doctor or pharmacist, since you may be able to set up an individualized treatment plan that works for you.

Curious why people are more sensitive to caffeine after quitting smoking? Check out my other article here.

Dan Landry

Daniel (Dan) Landry, founder of Rxplanation.com, is an infectious diseases pharmacist at the Dr-Georges-L.-Dumont University Hospital Centre in Moncton, NB, Canada.

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