Conquering Nicotine Dependence
We previously discussed the fact that nicotine addiction is one of the main reasons for a smoker’s inability to quit. This addiction can be physiological, psychological, or both. If your nicotine addiction is physiological, the short-term replacement of nicotine in your body by a method other than smoking may be the answer.
Nicotine replacement strategies use items other than cigarettes to replace the nicotine in your body in order to help ease your physical withdrawal from cigarettes. With this method, you’ll be much more comfortable when you quit smoking.
There are four methods of nicotine replacement. The first one, smokeless tobacco, is dangerous. The second, lobeline tablets, does not work very well. Only the nicotine gum and the nicotine patch are approved by the Food and Drug Administration (FDA) as aids to smoking cessation. Let’s discuss these methods, as well as some methods currently under development.
Smokeless Tobacco
The oral use of smokeless tobacco, usually in the form of chewing tobacco or snuff, is the worst type of nicotine replacement that a smoker can choose. With it, you do avoid tar, carbon monoxide, and the other components of smoke, but you leave yourself open to many other risks. The 1986 Surgeon General’s Report was devoted to smokeless tobacco and concluded that It represents a significant health fisk and is not a safe substitute for smoking cigarettes.
History
Chewing tobacco and snuff were popular far before cigarette smoking came. into vogue. In fact, there is evidence that Native Americans chewed tobacco to alleviate hunger pangs more than 5,000 years ago! The use of snuff in the United States was documented as early as the 1600s in the Jamestown Colony. It peaked in the nineteenth century and then declined as cigarettes became popular. Nevertheless, more than 12 million Americans currently use smokeless tobacco.
Preparation
Chewing tobacco is typically held in the cheek or lower lip. Snuff is much finer in consistency than chewing tobacco. It is usually placed in the mouth but not chewed. Tobacco sniffing is rare today.
There are many different types of smokeless tobacco. These products differ in where they are grown and cultivated, in which parts of the tobacco plant are used, in the method of curing, in moisture content, and in additives. In addition, some tobaccos contain flavorings like licorice, mint, or wintergreen.
Nicotine Exposure
Even though these tobacco products are smokeless, they contain substantial quantities of nicotine. Since nicotine can be absorbed well in your mouth, the exposure to nicotine from smokeless tobacco is equivalent to that of cigarettes. Consequently, the addiction produced by this level and frequency of nicotine intake is also similar to that of cigarette smoking.
Harms
What is the major reason that smokeless tobacco is not a reasonable alternative to cigarettes? Its use greatly increases the risk of cancer. There is evidence that the risks of cancer of the mouth, nose, esophagus, voice box, and stomach are increased by using smokeless tobacco.
Effectiveness
smokeless tobacco might seem to be a possible substitute for cigarettes, but you’ll derive very little benefit from such a switch. Not only would you remain addicted to nicotine, but also your health would continue to be endangered by your use of tobacco and its carcinogenic ingredients.
Recommendation
Avoid smokeless tobacco products.
Lobeline
Lobeline is a nicotine-like substance currently marketed as an over-the-counter smoking substitute that can be found at almost every drug store. Usually, in the aisle that contains the tobacco products, there are tablets containing lobeline sulfate that are touted as aids to smoking cessation.
History
Lobeline, discovered in 1915, is not a new product. Even before the health consequences of smoking were known for certain, there were people who wanted to quit. This substance has been used as a quitting aid since the 1930s, when lobeline capsules were first sold to decrease cigarette withdrawal symptoms. Over the years, lobeline has been taken either alone or in combination with other medicines, in the form of tablets, lozenges, or injection. (The injection, however, produces frequent gastric intestinal distress.) Lobeline is sold over-the-counter and through clinics, although by now, it has been abandoned by most legitimate clinics.
Preparation
Like nicotine, this substance is obtained from tobacco, but from a different type than that used in smoking products. Chemists be scribe lobeline as a less potent form of nicotine. It is marketed by many companies and under several trade names. For example, it might be found as Bantron tablets (by the JMI-Dep Corporation) or as CigArrest tablets or gum (by the Advantage Health and Fitness Corporation). The tablets usually contain 2 milligrams of lobeline and the gum contains .6 milligrams.
Effectiveness
The problem with lobeline, unlike nicotine gum (to be discussed next), is that there is no evidence that it helps anyone quit smoking. As a cigarette substitute, it does not seem to decrease cravings or increase rates of success.
The best thing that can be said about lobeline is that it does not appear to be harmful. The FDA has classified it as safe but not effective. High doses of lobeline, however, can cause abdominal pain, heartburn, nausea, and vomiting.
Recommendation
Although lobeline can be found in most drug stores as a quit-smoking aid, there is no scientific evidence to support its use. Yon should save your money and avoid products made with it.
Nicotine Gum And Patch
In the past decade, delivery of nicotine in ways other than through tobacco has emerged as an important method to help smokers quit. Currently, nicotine polacrilex chewing gum and the nicotine skin patch are the main methods of nicotine replacement that are approved by the FDA as aids to smoking cessation.
You may have concerns about replacing one form of addiction with another. First of all, the gum and patch are designed to be used for a short time. You’re not supposed to use them indefinitely. Most people can cut back on the gum or the patch gradually. A small percentage, though, will want to continue to use them. This is not recommended. But it is usually easier to help someone quit the gum or the patch than to quit smoking.
Secondly, while it is true that there is some addictive potential to nicotine gum and the patch, it is much less so than that to cigarettes. Neither the gum nor the patch creates dependence. Rather, each transfers dependence on nicotine to a different source.
You also may have concerns about exposing yourself to nicotine. Although nicotine has many effects on the body, its addictiveness is its most dangerous quality. Fortunately, nicotine taken as gum or from the patch does not have the same power as nicotine taken as smoke. Most of the more dangerous effects of cigarettes corne from inhaling the smoke, not simply from exposure to the nicotine. The gum and the patch are much safer than smoking.
History
The idea of helping smokers to quit by replacing the nicotine from their cigarettes with nicotine from another source is not entirely new. In the early 1940s, a scientist reported the effects of injecting nicotine directly into the bloodstream. This method, however, was impractical to help smokers. It was not until much later that a new strategy to replace the nicotine source was introduced. In the early 19705, investigators from Sweden reported the development of a gum that released nicotine slowly as it was chewed. It took ten more years, however, before it was available in the United States. Almost another ten years later, in 1992, another method of delivering nicotine, the nicotine patch, was approved in the United States.
Who Should and Who Shouldn’t Use the Gum or Patch?
The gum and patch are designed for smokers who are physically dependent on nicotine. According to the manufacturer of Ni-Corette gum, the smokers most likely to benefit: Smoke more than fifteen cigarettes per day.
- Prefer brands of cigarettes with higher nicotine levels.
- Usually inhale deeply and frequently.
- Smoke their first cigarette within thirty minutes of rising in the morning.
- find the first cigarette in the morning to be one of the hardest to give up.
- smoke more frequently in the morning than the rest of the day.
- find it difficult to refrain from smoking in places where it is forbidden.
- smoke even when they are ill.
There are also people who should not use these products. The effects of nicotine on the heart are similar whether the exposure occurs through smoking or through the gum or patch. In either case, there is an increase in heart rate and blood pressure. For this reason, the nicotine gum and patch are not recommended for people who have recently had a heart attack, who have a history of potentially dangerous heart-rhythm disturbances, or who have significant coronary artery disease.
Also, a woman who is pregnant or trying to become pregnant should not use nicotine gum or the nicotine patch. Nicotine (whether the exposures by smoking, gum, or patch) may harm the fetus, possibly by causing decreased blood flow to the uterus. Nicotine should also be avoided while a woman is breastfeeding since nicotine passes freely into breast milk.
Individuals with a history of inflammation either in the esophagus or farther down the intestinal tract, or who have stomach ulcers, should only use the gum with extreme caution. The same thing goes for those individuals who have inflammation in the mouth or throat.
It should be noted, however, that for all of these people, nicotine replacement with the patch or gum is probably safer than the continued use of cigarettes.
Nicotine Gum
The Nicorette brand of gum was introduced to the public in the spring of 1984. It was heavily promoted through a multimillion dollar marketing campaign. Consequently, it soon became one of the fastest selling prescription medications, with sales exceeding $50 million within its first three years. There are estimates that one-tenth of all smokers have used this product.
Description of the Product
Nicotine polacrilex chewing gum is a sugar-free gum that is distributed by Marion-Merrell Dow Pharmaceuticals under the brand name Nicorette (nicotine resin complex). It is available only by prescription. Each piece of regular-strength gum contains 2 milligrams of nicotine and each piece of double-strength Nicorette DS gum contains 4 milligrams. Both also contain other chemicals, such as antacids, which help the mouth membranes absorb the nicotine.
Effectiveness
There is little dispute that nicotine gum alleviates many of the withdrawal symptoms associated with smoking cessation. Many studies have confirmed this finding. It’s interesting, though, that the gum does not seem to suppress all the symptoms equally. For example, irritability seems to be blunted or reduced, but the craving, or the strong urge to smoke, is not always decreased. Also, hunger, depression, anxiety, and many other symptoms are reduced in some smokers using the gum but not in others. There is some evidence that weight gain can be lessened by the gum.
However, the most important question about nicotine gum is whether or not the replacement helps smokers quit. Although several studies have investigated this question, there remains some controversy about the gum’s effectiveness. One of the problems is that there really isn’t any conclusive research that shows whether or not smokers stay off tobacco once they stop using the nicotine gum. Don’t be surprised if you hear different points of view about this popular intervention.
Nevertheless, most authorities believe that nicotine gum can be an effective aid to smoking cessation. After years of research, two factors have emerged as important to the success of nicotine gum. First, it must be given in an adequate dosage. This means that you must use it as prescribed (more about this below). Second, the gum must be accompanied by a structured quit-smoking program. This is a fairly surprising finding that has been confirmed by many studies. They show that if prescribed nicotine gum is used without any other quit-smoking strategies, it does little to increase the success rates of smokers trying to quit. The explanation is that the gum helps physical dependence but does nothing for psychological dependence.
Chewing Procedure
Nicotine is absorbed through your gums. Therefore, moisten the gum and bite down on it slowly. You should feel a peppery taste or tingling when the nicotine is released. When you notice this feeling, “park” the gum between your cheek and gums. When the feeling goes away, probably in about a minute, chew again until it returns. Repeat the process. (Don’t worry if you swallow the gum. You should not feel any side effects.) The reason for the starting-and-stopping chewing pattern is to let the maximum nicotine benefit without getting sick. Each piece ghould be used for twenty to thirty minutes and then discarded. It may take up to twenty minutes for nicotine from the gum to be absorbed by your body. Therefore, try to anticipate your cravings for a cigarette, from which the nicotine takes only seven seconds to get into your body! If too much time goes by between the start of your craving for a cigarette and when you take the gum, your reSOlve as an ex-smoker may weaken. You want the gum to help you remain an ex-smoker, right?
How Much Gum Should You Use?
The gum should be used liberally to prevent or treat Withdrawal symptoms. Furthermore, the gum should be used for at least a few months. In the first month, do not worry about the amount you chew as long as it is under thirty pieces a day. Although its use is not officially recommended for longer than six months, some people use it for much longer. If you do discontinue use of the gum, you may Want to carry some with you anyway, in case a craving hits. With the recent FDA approval of the high-dose fonnulation of gum, Nicorette DS, which has 4 milligrams of nicotine as compared to the regular-strength gum’s 2 milligrams, it is now possible to design a gum program in which you taper your exposure to nicotine over a period of a few months. Smokers who are heavily dependent on nicotine can begin their smoking-cessation program with the low-dose gum, then can move down to the low-dose gum.
Warning
Coffee, juices, and carbonated beverages block the absorption of nicotine from the gum. It seems that these beverages change the chemistry of saliva just enough to make nicotine gum ineffective. This was discovered by some researchers who noticed that many chewers did not receive the dose of nicotine that they expected they would. Many of these people drank coffee, fruit juices, or soft drinks either just before or while chewing the gum. A careful experiment proved the researchers’ suspicions to be true. The current recommendation, therefore, is to avoid these drinks just before or while the gum is chewed.
Stopping the Gum
Despite the recommendation that nicotine gum not be used for more than a few months, many people find it difficult to stop. It seems that about one in twenty smokers who turn to the gum still chew it one year later. Of the smokers who are successful in quitting cigarettes with the use of nicotine gum, one in four continues using the gum up to one year later.
Long-term use is not known to cause health problems. The gum is what many people believe is keeping them free of cigarettes. Given that the gum does not contain the tar, carbon monoxide, and other harmful components of smoke, it seems preferable to smoking. In this way, it seems, the gum is helping both the physiological and psychological dependence.
When you are ready, give up the gum gradually. Since the gum does contain nicotine, if you stop abruptly you may feel some physical withdrawal. Most people find the process mostly painless.
Side Effects
There are some side effects associated with nicotine gum, but they occur rarely and are often minor, relating either to the gum chewing itself or to the chemical. They include problems with dental work, aching jaw muscles, mouth irritation, excessive salivation, indigestion, dizziness, insomnia, headaches, irritability, hiccups, lack of appetite, and, more commonly, abdominal discomfort, nausea, and indigestion.
Overdosage almost never occurs accidentally. Symptoms of acute nicotine overdose include nausea, salivation, abdominal pain, vorniting, diarrhea, cold sweats, headache, dizziness, and confusion.
Getting the Gum
Nicotine gum must be prescribed by a physician. However, any hysician who merely writes you a prescription for the gum is not really helping you. The prescription should be accompanied by a plan to quit smoking, preferably one that is organized and structured. You should also be instructed on the use of the gum.
Nicotine Patch
Nicotine patches were introduced in 1992 amid much fanfare. Millions of dollars have been spent advertising the merits of this smoking-cessation method. Newspapers and magazines are sprinkled with ads promoting the patch. Fortunately, this is a case in which the product will likely live up to its billing!
Description
Most nicotine patches look like large round Band-Aids. They contain a small amount of nicotine embedded in a special material. This material is kept in close contact with the skin by an adhesive.
Effectiveness
There are many reports that the nicotine patch reduces cigarette cravings, and recent findings have demonstrated that it can improve success rates among smokers who want to quit.
A recent report in The New England Journal of Medicine studied the safety and effectiveness of nicotine skin patches designed to release nicotine into the smoker’s body over a sixteen-hour period. Subjects were given patches that were to be placed on the skin in the mOrning and taken off at night. Some were given patches that did not contain nicotine. No special counseling program accompanied this intervention.
The researchers found that the subjects given the real nicotine patches were more successful in quitting. The success rate at six weeks was 53 percent in the nicotine-patch group and 17 percent in the other. At the end of a year, the success- rate was 17 percent in the nicotine-patch group and 4 percent in the other group. Symptoms of nicotine withdrawal tended to be less in the nicotine-patch group.
Another study involved nine medical centers and 935 patients. At the six-month mark, 1 in 4 subjects treated with the nicotine patch remained a nonsmoker as compared with 1 in 9 subjects treated with a patch that contained no nicotine. These studies provide compelling scientific evidence that the patch is an effective aid for smoking cessation. There are few other methods that have undergone such screening by the medical community and have been found to be beneficial.
How to Use the Patch
The patches come in various strengths induding 22, 21, 15, 14, 11, 10, 7, and 5 milligrams, depending on the manufacturer. The size of the patch is proportional to the amount of nicotine in it. Therefore, the 21-milligram patch is the largest and the 7-milligram patch is the smallest.
The pa tches may be used in a variety of different programs. One approach is to use a larger patch for six weeks and then move to smaller patches for two weeks each. Some people use the larger patch for a longer time. There is no magic way to tell when you are ready to switch to a smaller patch.
It is usually recommended that at six weeks you give a smaller patch a try. If you have trouble with symptoms when you switch, then you can always return to the larger patch. As with the nicotine gum, you should not use the patch unless you have stopped smoking.
The importance of this warning is highlighted by the recent reports of heart attacks in people who were wearing a patch and smoking. Although the contribution of the double dose of nicotine to the heart attack cannot be proven, there is concern among some physicians that the added nicotine played a role.
Side Effects
In recent large studies of the nicotine patch, there have been very few reported side effects. The most common complaint has been mild itchiness that lasted for fifteen to thirty minutes after placing the patch on the skin.
Common Questions About the Nicotine Patch
Does matter at what time of day you apply the patch?
The time of day is not important. The patch can be put on at any time of the day or night, and this time can vary. All that you need to do is take off the old one and put on the new one.
Can you take a shower if you’re wearing the patch?
The patch was designed to get wet without losing adhesiveness or effectiveness. You can bathe, swim, or shower while wearing it.
What if the patch falls off?
The patch is designed to stick well. If it does fall off, however, simply replace it. It is a good idea to carry an extra patch with you just in case you need it.
Which patch should you use?
Patches should usually be started at the strongest strength. For Nicoderm and Habitrol, you should start with 21 milligrams per day; for Prostep, the 22-milligram strength; and for Nicotrol, 15 milligrams. For smokers who weigh less than 100 pounds, smoke less than half a pack of cigarettes perday, or who have cardiovascular disease, it may be preferable to start with a lower dose.
Physicians and Nicotine Replacement
Physicians may not always be the best source of information about nicotine replacement. A recent survey of California physicians practicing general medicine revealed that many were misin formed about the use of nicotine gum, even though almost 90 percent had prescribed it within the last year. Almost half of these physicians believed that, even if their patien,ts did not stop smoking, they should use the gum to cut down on cigarettes. In addition, contrary to recommendations from authorities on smoking cessation, one in four of the doctors thought that the gum should not be used for more than one month.
The message is that not all doctors are informed (or even interested) in smoking cessation. It is your responsibility to educate yourself. If you are ready to quit, find a physician who knows about the gum or is familiar with the patch and has experience prescribing it.
Should You Use the Gum or the Patch?
In many ways, the patch may be an improvement over the gum. The use of the patch is easy to master. It is unobtrusive and socially acceptable. Also, it may be better for you to be exposed to a low level of nicotine over sixteen or twenty-four hours rather than to the small bursts that the gum provides. No one has yet, however, compared the gum to the patch. Since the gum has been in use for almost ten years in this country, it remains an important standard strategy. It can also satisfy the need of some smokers for oral stimulation. The important point is that nicotine replacement, whether by gum or patch, is one of the best methods of helping you to quit smoking. Its benefit is proven scientifically by studies published in prestigious medical journals.
Possibilities For Future Nicotine Substitution
While nicotine gum is being widely used and the nicotine patch is the current rage, other methods of administering nicotine are being developed. Among those that scientists are currently testing are nicotine nasal sprays, smokeless cigarettes, and nicotine aerosols.
Nicotine nasal spray administers nicotine via gel-like droplets of liquid. Patients can achieve higher levels of nicotine with the spray than with the gum. Each pump of the spray bottle delivers about one-half milligram of nicotine, and repeated pumps can give you exposure to the same amount of nicotine as in a cigarette.
Some researchers are very optimistic about the nasal spray. In the August 8,1988, issue of the British medical journal The Lancet, a group of researchers from London confirmed that nasal nicotine spray is truly effective as an aid to smoking cessation. The group studied the value of the nasal spray in over 200 smokers by giving real nicotine spray to half of the subjects and spray that did not contain nicotine to the other half. The subjects were not told which spray they had. Both groups attended quit-smoking sessions designed to help them succeed. After one year, the group that used the nasal spray with nicotine was more than twice as likely to be ccessful than the nicotine-less group (26 percent versus 10 percent). The benefit of the nicotine spray was greatest for the heaviest smokers. The spray reduced withdrawal symptoms, cravings, and weight gain. There were no serious side effects reported, although some people found the spray irritating at first. The biggest problem may be that many people are too embarrassed to squirt liquid into their nose in public. Advocates of the spray claim that it may be better than the gum or patch because, like cigarettes, it provides a burst of exposure to nicotine. There is, however, no evidence that it is better than what is already available.
A smokeless cigarette is also being investigated. This is a plastic, cigarette-shaped tube. It contains a nicotine-soaked fibrous material that provides a dose of nicotine each time it’s dragged on. Since it is not lit, its use can be extended way beyond that of a cigarette.
In addition, a nicotine aerosol is being developed. This device allows nicotine to be inhaled without cigarette smoke. It may be helpful for people who need a boost of nicotine greater than what the gum or nasal spray can provide.
Warning
Nicotine replacement does not guarantee success in your quest to quit smoking. It can help you, but the responsibility for success remains yours. Do not be lulled into thinking that this method will accomplish this challenging task for you.
