Written by SMH Emergency Clinical Pharmacist Kathryn Samai & PharmD Candidate Joshua Allman
Are you a cigarette smoker? If so, you no doubt want to quit but struggle with making it happen.
Nearly seven in 10 smokers want to quit, according to the US Centers for Disease Control and Prevention. Smokers looking to break the addiction should consider using nicotine replacement therapy (NRT), especially if they smoke more than a few cigarettes each day or have made past quit attempts that were unsuccessful.
What is Nicotine Replacement Therapy?
Nicotine replacement products include gums, lozenges, patches, inhalers and even nose sprays that contain nicotine. Using these products can reduce the nicotine cravings and withdrawal symptoms that come with quitting smoking, allowing you to focus the psychological and emotional aspects of breaking the habit. In fact, smokers who use nicotine replacement products during a quit attempt are almost twice as likely to be successful than those who don’t.
Nicotine Replacement Pros & Cons
With so many types of NRT products on the market, choosing one can seem overwhelming. Understanding the pros and cons of each will help you choose the best one for your needs and determine whether using nicotine replacement is right for you.
NRT products are not a good choice for all smokers looking to quit. If you have had a recent heart attack or have other heart problems, like chest pains or an irregular heartbeat, NRT is not recommended. If you are pregnant or younger than 18, NRT is not recommended (neither is smoking, of course). Also, because NRT products are designed to replace the nicotine you would get from tobacco, you should not use NRT while you are still smoking.
With those general limitations in mind, let’s take a look at the different nicotine replacement options.
Nicotine Gum & Lozenges
Nicotine gum and nicotine lozenges are a great option for most smokers. They don’t require a prescription, and the amount of nicotine can be easily adjusted based on cravings. Gum and lozenges also help satisfy the “oral fixation” associated with smoking.
To determine which strength (nicotine dose) of gum/lozenges to start with, think about when you smoke your first cigarette each day. If you smoke your first cigarette less than 30 minutes after waking up, start with the 4-milligram gum or lozenges. If you generally wait longer than 30 minutes, start with 2 milligrams.
Some people have trouble keeping up with the frequent usage most smokers need for gum/lozenges to be effective. Regardless, it is best to use them on a regular schedule; if you wait until a craving hits, they may not be much help.
Brands: Nicorette, generic, store brands
Strengths: 2 mg and 4 mg
Dosing: Use one piece of gum or one lozenge every one to two hours (maximum 24 pieces/day); gradually reduce strength and frequency over time.
Duration: 12 weeks
Like the gum and lozenges, nicotine patches do not require a prescription to purchase. Advantages of nicotine patches include that only one patch per day is used, and the small clear patches can be easily hidden under clothing. To decide which strength to use, count how many cigarettes you smoke in a typical day. If you smoke 10 or more cigarettes, start with 21-milligram patches; if you smoke fewer than 10 per day, start with 14-milligram patches.
One common side effect of the patches is disrupted sleep, especially for those who the leave the patch on while sleeping. To avoid this, some users remove the patch at bedtime and put on a new one each morning.
Brands: NicoDerm CQ, generic, store brand
Strengths: 7 mg, 14 mg and 21 mg
Dosing: Apply one new patch each day; switch to lower-strength patches after four weeks
Duration: Eight to 10 weeks
It’s important to talk with your healthcare provider(s), if you’re interested in a prescription nicotine replacement inhaler or nose spray. Not only do they require a prescription, but their effectiveness is highly dependent on proper technique with use, so your healthcare team will want to make sure you know how to use them correctly. The main advantage of these is that they are fast-acting, which makes them good for sudden urges or intense cravings.
Brand: Nicotrol oral inhaler
Strength: 10 mg
Dosing: Puff one cartridge for 20 minutes every one to two hours; start with at least six cartridges per day (max 16 cartridges/day)
Duration: Three to six months
Brand: Nicotrol NS nasal spray
Strength: 10 mg/mL
Dosing: One spray in each nostril one to two times per hour (max 40 sprays in each nostril/day)
Duration: Three to six months
Prescription medications are not nicotine replacement products, but you can use them in conjunction with NRT or by themselves to quit smoking. Their simple, once- or twice-daily dosing makes them easy to use. If you use these prescription medications, be sure to start taking them before your quit date to help you proactively manage withdrawal symptoms. Common side effects include sleep problems, nausea and constipation, but in rare cases, they can cause more serious side effects such as seizures, mood changes or suicidal thoughts.
Brand: Chantix (varenicline)
Dosing: Start with one 0.5 mg pill every morning for three days, then 0.5 mg twice daily for four days, then 1 mg twice daily
Duration: 12 weeks for most people; start one to 12 weeks before quit date
Brand: Zyban SR (bupropion)
Dosing: Start 150 mg every morning for three days, then 150 mg once or twice daily
Duration: Seven to 12 weeks (may be used up to six months for some people); start one to two weeks before quit date
Comprehensive Quit Plan
Finally, and perhaps most importantly, know that nicotine replacement therapies and prescription medications are just part of a successful plan to quit smoking. There are many other resources available, such as support groups, counseling, phone apps and more. NRT is most effective if it is used in conjunction with other strategies.
Remember, nicotine replacement products help manage only the physical symptoms. In order to kick the habit for good, your plan should also address the psychological and emotional effects of quitting smoking. (Check out SMH's calendar and Facebook event listings for upcoming "Quit Your Way: Free Tools & Class to Quit Smoking" sessions.)
If you’re thinking about quitting, visit smokefree.gov to learn more about your options and talk with your healthcare team. Your doctor, pharmacist and other healthcare or wellness providers want to help you quit and connect you with the resources to create the best possible quit plan! Good luck!
An SMH Emergency Medicine clinical pharmacist, Kathryn Samai, Pharm.D., BCPS, earned her Doctor of Pharmacy degree from the University of Florida and is a board-certified Pharmacotherapy specialist. She also is a member of the Pharmacy Research Oversight Committee, Code Blue Response Team and Pharmacy/Toxicology Team.
A fourth-year Doctor of Pharmacy candidate at the University of Florida College of Pharmacy, Joshua Allman has completed Advanced Institutional, General Medicine and Critical Care rotations at Sarasota Memorial Hospital.