What are the types of nicotine replacement therapy?
The US Food and Drug Administration (FDA) has approved 5 types of nicotine replacement therapy:
- Nasal spray
Nicotine patches (transdermal nicotine systems): Patches give a measured dose of nicotine through the skin. You are weaned off nicotine by switching to lower-dose patches over a course of weeks. Patches can be bought with or without a prescription. Many types and different strengths are available. Package instructions tell you how to use the product, and list special considerations and possible side effects. Follow the directions carefully.
The 16-hour patch works well if you are a light-to-average smoker. It’s less likely to cause side effects like skin irritation, racing heartbeat, sleep problems, and headache. But it does not deliver nicotine during the night, so it may not be right for those with early morning withdrawal symptoms.
The 24-hour patch provides a steady dose of nicotine, avoiding peaks and valleys. It helps with early morning withdrawal. But there may be more side effects like disrupted sleep patterns and skin irritation.
Depending on body size and smoking habits, most smokers should start using a full-strength patch (15-22 mg of nicotine) daily for 4 weeks, and then use a weaker patch (5-14 mg of nicotine) for another 4 weeks. The patch should be put on in the morning on a clean, dry area of the skin without much hair. It should be placed below the neck and above the waist — for example, on the upper arm or chest. The FDA has approved using the patch for a total of 3 to 5 months.
Side effects are related to:
- The dose of nicotine
- The brand of patch
- Skin characteristics and allergies (some people have reactions to the patch)
- How long the patch is used
- How it is applied
Some possible side effects of the nicotine patch include:
- Skin irritation (redness and itching)
- Racing heartbeat
- Sleep problems or unusual dreams
- Muscle aches and stiffness
No one has all of the side effects, and some people have none. Some side effects, such as racing heart, may occur because the dose of nicotine is too high for you. Stop using the patch and talk to your doctor if this happens. You can also have nicotine withdrawal symptoms during this time if your NRT dose is too low.
What to do about side effects
- Do not smoke while you are using a patch unless your doctor tells you it’s OK.
- Try a different brand of patch if your skin becomes irritated.
- Reduce the amount of nicotine by using a lower-dose patch.
- Sleep problems may go away in 3 or 4 days. If not, and you’re using a 24-hour patch, try switching to a 16-hour patch.
- Stop using the patch and try a different form of NRT.
Nicotine gum (nicotine polacrilex): Nicotine gum is a fast-acting form of replacement in which nicotine is taken in through the mucous membrane of the mouth. You can buy it over the counter without a prescription. It comes in 2 mg and 4 mg strengths.
For best results, follow the instructions in the package. Chew the gum slowly until you get a peppery taste or tingle. Then hold it inside your cheek until the taste fades. Chew it to get the peppery taste back, and park it again. Do this off and on for 20 to 30 minutes. Food and drink can affect how well the nicotine is absorbed, so don’t eat or drink for at least 15 minutes before and during gum use.
In choosing your dose, think about whether you
- Smoke 25 or more cigarettes per day
- Smoke within 30 minutes of waking up
- Have trouble not smoking in restricted areas
If any of these describe you, you may need to start with the higher gum dose (4 mg).
Chew no more than 24 pieces of gum in one day. Nicotine gum is usually recommended for 6 to 12 weeks, with the maximum being 6 months. Tapering down the amount of gum you use as you approach 3 months may help you stop using it.
If you have sensitive skin, you might prefer the gum to the patch.
Another advantage of nicotine gum is that it allows you to control the nicotine doses. The gum can be used as needed or on a fixed schedule during the day. The most recent research has shown that scheduled dosing works better. A schedule of 1 to 2 pieces per hour is common. On the other hand, with an as-needed schedule, you can use it when you need it most — when you have cravings.
Some possible side effects of nicotine gum:
- Bad taste
- Throat irritation
- Mouth sores
- Jaw discomfort
- Racing heartbeat
The gum can also stick to and damage dentures and dental work.
Symptoms related to the stomach and jaw are usually caused by improper use of the gum, such as swallowing the nicotine or chewing too fast. No one has all of the side effects, and some people have none. If your heart is racing or beating irregularly, stop using the gum and talk to your doctor. You can also have nicotine withdrawal symptoms during this time if your NRT dose is too low.
Long-term dependence is one possible drawback of nicotine gum. In fact, research has shown that 15% to 20% of gum users who are able to quit smoking keep using the gum for a year or longer. Nicotine is addictive, and people can transfer their dependence from cigarettes to the gum. The maximum recommended length of use is 6 months, but continuing to use the gum may be safer than going back to smoking. Because there’s little research on the health effects of long-term nicotine gum use, most health care providers still recommend limiting its use to 6 months. Talk to your doctor if you are having trouble stopping the gum.
Nicotine nasal spray: The nasal spray delivers nicotine to the bloodstream quickly because it’s absorbed through the nose. Nicotine nasal spray requires a doctor’s prescription.
The nasal spray relieves withdrawal symptoms very quickly and lets you control your nicotine cravings. Smokers usually like the nasal spray because it’s easy to use. Nicotine is addictive, and a person can transfer their dependence from cigarettes to the fast-delivering nasal spray. Use it only as long as you need it, as prescribed by your doctor. The FDA recommends that the spray be prescribed for 3-month periods and that it not be used for longer than 6 months.
The most common side effects last about 1 to 2 weeks and can include:
- Nasal irritation
- Runny nose
- Watery eyes
- Throat irritation
There’s also the danger of using more than is needed. If you have asthma, allergies, nasal polyps, or sinus problems, your doctor may suggest another form of NRT.
This form of NRT poses a more serious risk to small children and pets, since even empty bottles of nasal spray contain enough nicotine to harm them. Nicotine absorbs through the skin as well as mucous membranes like the mouth or eyes, and can cause serious harm. If there’s any skin contact, rinse thoroughly with plain water right away. If a bottle breaks or liquid leaks out, put on plastic or rubber gloves to clean it up. Call Poison Control and get emergency help if there’s any question of overdose.
Nicotine inhalers: Inhalers are available only by prescription. The nicotine inhaler is a thin plastic tube with a nicotine cartridge inside. It looks a bit like a fat cigarette with a mouthpiece. When you take a puff from the inhaler, the cartridge puts out a nicotine vapor. Unlike other inhalers, which deliver most of the medicine to the lungs, the nicotine inhaler delivers most of the nicotine vapor to the mouth where it’s absorbed into the bloodstream. Nicotine inhalers are the FDA-approved nicotine replacement method that’s most like smoking a cigarette, which some smokers find helpful.
The recommended dose is between 4 and 20 cartridges a day, for up to 6 months.
The most common side effects, especially when first using the inhaler, include:
- Throat irritation
- Upset stomach
This form of NRT poses an extra risk to small children and pets because the used cartridges still have enough nicotine in them to cause harm if it gets on skin or mucous membranes (for instance, if licked or touched to the eyes, mouth, or other mucous membrane). Be sure to store and dispose of the cartridges away from children and pets.
Nicotine lozenges: Nicotine-containing lozenges can be bought without a prescription. Like nicotine gum, the lozenge is available in 2 strengths: 2 mg and 4 mg. Smokers choose their dose based on how long after waking up they normally have their first cigarette.
Lozenge makers recommend using them as part of a 12-week program. The recommended dose is 1 lozenge every 1 to 2 hours for 6 weeks, then 1 lozenge every 2 to 4 hours for weeks 7 to 9, and finally, 1 lozenge every 4 to 8 hours for weeks 10 to 12. The lozenge makers also recommend:
- Stop all smoking when you start using the lozenge.
- Do not eat or drink for 15 minutes before using a lozenge. (Some drinks can reduce how well the lozenge works.)
- Suck on the lozenge until it is fully dissolved, about 20 to 30 minutes. Do not bite or chew it like a hard candy, and don’t swallow it. The nicotine absorbs through the mucous membranes of the mouth.
- Do not use more than 5 lozenges in 6 hours, or more than 20 lozenges per day.
- Stop using the lozenge after 12 weeks. If you still feel you need to use the lozenge, talk to your doctor.
- Do not use the lozenge if you keep smoking, chewing tobacco, using snuff, or use any other product containing nicotine (such as the nicotine patch or nicotine gum).
Possible side effects of the nicotine lozenge include:
- Trouble sleeping
- Flatulence (gas)
Which type of nicotine replacement may be right for you?
There’s no evidence that any one type of nicotine replacement therapy (NRT) is any better than another. When choosing which type of NRT you will use, think about which method will best fit your lifestyle and pattern of smoking. Do you want/need something in your mouth or something to keep your hands busy? Or are you looking for once-a-day convenience?
Some important points to think about:
- Nicotine gums, lozenges, and inhalers are substitutes you can put into your mouth that let you control your dosage to help keep cravings under better control.
- Nicotine gums and lozenges are generally sugar-free, but if you are diabetic and have any doubts, check with the manufacturer.
- Nicotine nasal spray works very quickly when you need it.
- Nicotine inhalers allow you to mimic the use of cigarettes by puffing and holding the inhaler. It also works very quickly.
- Nicotine patches are convenient and only have to be put on once a day.
- Both inhalers and nasal sprays require a doctor’s prescription.
- Some people may not be able to use patches, inhalers, or nasal sprays because of allergies or other conditions.
- Nicotine gum may stick to dentures or dental work making it hard to chew before “parking.”
Whatever type you use, take your NRT at the recommended dose, and use it only for as long as it’s recommended. If you use a different dose or stop taking it too soon, it can’t be expected to work like it should. If you are a very heavy smoker or a very light smoker, you may want to talk with your doctor about whether your NRT dose should be changed to better suit your needs.
Combining the patch and other nicotine replacement products: Using the nicotine patch along with shorter-acting products, like the gum, lozenge, nasal spray, or inhaler, is another method of NRT. The idea is to get a steady dose of nicotine with the patch and then use one of the shorter-acting products when you have strong cravings.
The few studies that have been done on combination NRT used this way have found that it may work better than a single product. Still, more research is needed to prove this and find safe and effective doses. And the combined use of NRT products has not yet been approved by the FDA. If you’re thinking about using more than one NRT product, be sure to talk it over with your doctor first.
High-dose nicotine replacement therapy for heavy smokers: Another NRT option is to give smokers a higher dose based on the amount of nicotine that they have been getting from cigarettes. Sometimes this method has required larger than usual doses of NRT. High-dose NRT with patches has been studied with patients getting from 35 mg to 63 mg of nicotine per day. The research suggests that patients’ withdrawal symptoms go away with these higher doses and their cravings improve without harmful effects on the heart and circulation. Patients were carefully watched in these studies to make sure they were OK and were not becoming ill or having any problems. But not much is known about this option and it should be considered only with a doctor’s guidance and supervision. It may worsen things if you already have heart disease or other health problems.
Stopping nicotine replacement therapy
As mentioned before, most forms of NRT are meant to be used for limited periods of time. Use should be tapered down to a low dose before NRT is stopped.
Research is still being done to refine the use of NRT. For example, even though the patch is usually used for 3 to 5 months, some studies have suggested that using it for 8 weeks or less works just as well. But other researchers have noted that the risk of relapse goes up when nicotine replacement is stopped, even after it has been used for 5 months. These differences have not been fully explained. More studies are needed to learn which smokers are likely to be successful using shorter or longer NRT than usual. If you feel that you need NRT for a different length of time than is recommended, it’s best to discuss this with your doctor.