Choosing the right nicotine replacement therapy (NRT)

Quitting smoking is hard, but it can be done.

The main reason it is so challenging is that nicotine is physically addictive. The people who are most successful at quitting use a combination of nicotine replacement therapy (NRT) and prescription medications to help them stop smoking. In fact, using NRT increases your chances of quitting by 50-70%. NRT gives you small amounts of nicotine, without the other harmful chemicals in tobacco, and relieves some of the physical withdrawal symptoms, such as cravings, headache, dizziness and irritability.

There are five types of NRT available in the U.S.: the transdermal nicotine patch, nicotine gum, nicotine lozenge, nicotine nasal spray and nicotine inhaler. Three of these options are available without a prescription. Note that vapes, hookahs and e-cigarettes are not NRT. Check with your health care provider before starting NRT if you have heart problems or other chronic illnesses, are pregnant or breastfeeding, or if you are under 18 years of age. Look at the label for information about the recommended doses for each product, which are based on how much you smoke, and be careful not to overuse NRT products.

If you are considering NRT, ask yourself the following questions to help you choose the best NRT for you:

• Do you want or need something in your mouth to help keep from reaching for a cigarette? Do you want flexibility with flavors or when to use the product? Consider using gum or lozenges.
• Are you looking for once-a-day convenience? Think about using a patch.
• Do you wear dentures or have other dental work that may interfere with some NRT products, such as gum or lozenges? Consider a patch or nasal spray.
• Do you have any allergies or conditions that may make you unable to use certain products? Talk with a pharmacist to make sure you are not inadvertently taking an allergen.

Transdermal nicotine patch

Transdermal nicotine patches provide nicotine for 24 hours once applied to the skin. Each day you have to remove the old patch and apply a new patch to a clean, dry area of your body that is not hairy. Your arms, thighs, stomach, chest or back may be good options. Rotate the places on your body where you apply the patch to decrease your chance of having skin irritation. If you begin to experience trouble sleeping, you can remove the patch at bedtime.

Pros:

• The patch can be worn under clothing so no one will know it's there.
• Nicotine is released constantly over 24 hours, so you can change the patch each day and forget about it. You won't have early morning withdrawal symptoms since you will get nicotine while you sleep.
• It may be covered by health insurance if you have a prescription.

Cons:

• You cannot adjust the dose to quickly manage withdrawal symptoms or cravings.
• The patch may cause headaches, skin reactions, such as itching, burning, or redness at the spot where it is applied, or sleep disturbances, such as insomnia or vivid dreams.

The patch is not recommended if you have any skin conditions or rashes. This is because the patch could make those conditions worse or your body may get too much or too little nicotine. Never cut the patch in half or in smaller pieces because that may cause you to get too much or too little nicotine.

Nicotine gum

Nicotine gum is available in a variety of flavors, including original, cinnamon, fruit, mint and orange. Dosage is based on when you have your first cigarette of the day and how many cigarettes you smoke every day.

Pros:

• Nicotine gum helps to satisfy oral cravings.
• You can adjust the dose quickly by chewing another piece to gum to manage withdrawal symptoms or cravings.

Cons:

• Using the gum can lead to mouth and jaw soreness, hiccups, indigestion or excessive salivation.
• The gum may be difficult to use for people with dentures or other dental work.

Begin by chewing one piece of gum every 1–2 hours for the first 6 weeks. Decrease to one piece every 2–4 hours during weeks 7–9, and then finish up treatment by chewing one piece every 4–8 hours during weeks 10-12.

Nicotine gum is not like normal gum that you chew when you want to and stop when you don't. This gum should be chewed slowly until you feel a tingling sensation and then "parked" in an area of your mouth. Once the tingling fades, repeat the process and "park" the gum in a different area of your mouth. Continue this for 30 minutes until the tingling sensation fades completely, which means that the nicotine in the gum is gone. You should avoid eating or drinking for 15 minutes before and after chewing nicotine gum, and limit gum to no more than 24 pieces a day.

Nicotine lozenge

Nicotine lozenges also come in several flavors. Appropriate dosage is based on when you have your first cigarette of the day.

Pros:

• Nicotine lozenges help satisfy oral cravings.
• You can adjust the dose quickly by sucking on another lozenge to manage withdrawal symptoms or cravings.

Cons:

• Nicotine lozenges may cause stomach upset, heartburn, gas, headaches, hiccups and coughing.
• The lozenges may make it difficult to fall asleep.

The directions for using lozenges are slightly less complicated than the gum. Start with one lozenge every 1-2 hours for the first 6 weeks; use one lozenge every 2-4 hours during weeks 7-9; and use one lozenge every 4-8 hours during weeks 10-12. Allow the lozenge to dissolve over 20-30 minutes in different areas of your mouth. Do not chew or swallow the lozenge and avoid eating or drinking 15 minutes before and after use. Do not use more than 20 lozenges per day.

Nicotine nasal spray

Nicotine nasal spray is available as a prescription and it provides 0.5mg of nicotine with each spray. You can use up to 5 doses (which equals 1–2 sprays in each side of the nose) per hour or 80 sprays per day, being mindful to use at least 8 doses per day. Make sure to avoid sniffing, swallowing or inhaling through your dose when administering the dose.

Pros:

• The dose can be adjusted quickly to manage withdrawal symptoms or cravings.

Cons:

• The nicotine nasal spray requires many doses which can cause nose or throat irritation.
• Side effects include headaches, sneezing, runny nose, tearing or cough.
• You should wait 5 minutes after a dose before driving or operating heavy machinery because of side effects.

When you're starting to quit smoking, you may be told to spray 1–2 times in each nostril, every hour. You should not spray more than 80 times in one day. You should not use the spray for longer than 6 months.

Nicotine inhaler

The nicotine inhaler looks like a plastic cigarette holder and requires a prescription. It consists of a mouthpiece and a cartridge that contains nicotine. This is different from a JUUL or a vape. Each cartridge contains 10mg of nicotine, but only 4mg becomes inhaled nicotine when the inhaler is used, so there will be some left once you finish. You can throw away whatever is left.

Pros:

• The inhaler can mimic the "puffing" from a cigarette helping to satisfy oral urges
• It quickly helps with withdrawal symptoms.

Cons:

• The inhaler requires a lot of doses.
• Side effects include mouth and throat irritation.

Using the nicotine inhaler is different from using other types of inhalers, such as those for asthma. The nicotine inhaler is "puffed" on by inhaling the medicine into the back of your throat or "puffing" in short breaths. Do not inhale into your lungs as you would a cigarette, but instead keep the puff in your mouth. It takes 20 minutes of active puffing to use up the entire 4mg dose. But if you use it for less time than that, the inhaler can be stored for later use with the same cartridge for up to 24 hours. Start by using at least 6 cartridges a day (with a maximum of 16 per day) and decrease over time. Most people use the inhaler for 3 months and then slowly decrease their daily use over the next 6–12 weeks. Also, avoid eating or drinking 15 minutes before or during use.

In summary, whatever you choose to use, be sure to:

• Talk with your health care provider before you use NRT if you have chronic illness, are pregnant or breastfeeding or are under 18 years of age.
• Follow the directions carefully, and do not overuse NRT. If you start experiencing side effects, know that they often go away if you use less NRT.
• For some people, using more than one type of NRT at a time can be more effective than using only one method alone. However, this could result in too much nicotine in your system. Speak with your provider or pharmacist if you plan to combine different types of NRT.
• If you smoke 10 cigarettes or more a day, talk with your provider to determine if you would benefit from a prescription medication as well as NRT.

If you or someone you care about wants to quit smoking, health care providers at the In-Store Clinics and MDLive are on hand to support you in your plans to be tobacco-free from cigarettes/rx-healthanswer or other forms of tobacco. There are additional educational materials available in the Walgreens Answer Centers on walgreens.com to support you as well.

Updated on September 9, 2019

Sources:

American Cancer Society. How to Quit Smoking. Accessed June 25, 2019.

https://www.cancer.org/latest-news/how-to-quit-smoking.html

Stead LF, Perera R, Bullen C, et al. Nicotine replacement therapy for smoking cessation. Cochrane Database Syst Rev. 2012 Nov 14: CD000146. doi: 10.1002/14651858.CD000146.pub4

Facts and Comparisons. https://online.factsandcomparisons.com/login/aspx

American Cancer Society. Nicotine Replacement Therapy for Quitting Tobacco https://www.cancer.org/healthy/stay-away-from-tobacco/guide-quitting-smoking/nicotine-replacement-therapy.html Retrieved 6/20/2019

Medline Plus Nicotine replacement therapy. https://medlineplus.gov/ency/article/007438.htm Retrieved 6/20/2019

The Ontario Medical Association. Facts about nicotine replacement therapy and smoking. https://tbrhsc.net/wp-content/uploads/2015/01/Nicotine-Replacement-Therapy-Facts.pdf Retrieved 6/20/2019