Tobacco Treatment: Medications

Although the nicotine in tobacco leads to a powerful addiction, people who want to stop smoking can be helped. Treatment to help people quit smoking is far less expensive than treatment of diseases caused by smoking, which will kill approximately one in two smokers who do not quit.

Examples of diseases that have been strongly linked to smoking include emphysema or chronic obstructive pulmonary disease, asthma, peptic ulcers, heart disease, and an increased risk of many types of cancer, including cancers of the mouth, pharynx, larynx, esophagus, stomach, pancreas, cervix, kidney, uterus, and bladder.

As early as the late 1890s, people were searching for medications that would help tobacco users quit. None of the products offered to the public between the early 1900s and the late 1970s were effective. As a result of important medical advances in the 1980s and 1990s, nicotine patches and nicotine gum came into use as effective treatments to help people quit smoking. Currently, the major accepted treatments for tobacco that use medications are nicotine replacement (products that provide nicotine through skin patches or gum) and symptomatic treatment (medications that do not provide nicotine, but that help decrease the craving for nicotine and the discomfort that occurs during withdrawal from the use of nicotine).

Nicotine Replacement

Of the 18 million smokers who try to quit each year, less than 7 percent do so successfully. In any given year, only about 1.7 million smokers quit for good. Most smokers who eventually quit successfully have between five and seven relapses before final success. Relapse is a common problem because of the unpleasant withdrawal symptoms smokers experience when they stop smoking. Smokers will often return to smoking to relieve those symptoms.

Nicotine replacement therapy substitutes a safer, more manageable, and less addictive form of nicotine to relieve the symptoms of nicotine withdrawal. The various forms of nicotine replacement include polacrilex (gum), transdermal delivery systems (patches), a vapor inhaler, and a nasal nicotine spray. These forms provide different doses and speeds of dosing.

Nicotine replacement offers several advantages. (1) The nicotine in patches and gum does not contain all the toxins (poisons) present in tobacco or produced by burning tobacco. In fact, a burning cigarette produces an amazing number of chemical compounds—including tar, formaldehyde, carbon monoxide, ammonia, and hydrogen cyanide— many of which are known poisons to the human body. (2) Total daily nicotine intake is lower for most patients on nicotine-replacement systems. Much more nicotine is delivered to the body by inhaling from cigarettes. (3) Nicotine replacement allows doses to be controlled more effectively than with tobacco products. Someone trying to quit smoking can gradually cut back on the amount of nicotine he or she is getting by decreasing the patch dosage or the amount of nicotine gum chewed over time. (4) Nicotine replacement protects others in the smoker's household from the dangers of secondhand smoke.

Nicotine Gum. Nicotine polacrilex (Nicorette®) is a chewing gum containing nicotine that is available by prescription as well as over the counter. Nicotine from the gum may not be absorbed well if the client does not follow directions carefully. Patients may have less success with gum than with other forms of nicotine replacement because many dislike the taste and experience some discomfort, such as slightly sore mouths, throats, and jaws and stomach upset. Nevertheless, a study at the Addiction Research Center of the National Institute on Drug Abuse (NIDA) found nicotine gum to be effective in treating symptoms of tobacco withdrawal.

See Organizations of Interest at the back of Volume 3 for address, telephone, and URL.

According to one manufacturer of nicotine gum, certain patients are more likely to benefit from this form of nicotine replacement. This treatment is most likely to benefit people who:

• have a high physical dependence on nicotine, preferring cigarette brands with nicotine levels over 0.9 milligrams
• find the first cigarette in the morning the hardest to give up
• smoke at least fifteen cigarettes per day
• smoke their first cigarette within fifteen minutes of awakening
• do most of their smoking in the morning

Patients who use nicotine gum should be warned that chewing many pieces of the gum at the same time or one after the other may cause a severe nicotine overdose.

Skin Patches. Four brands of nicotine patch are widely available in the United States. All deliver a given dose of nicotine through the skin over either a twenty-four hour (Habitrol, Prostep, and NicoDerm®) or a sixteen-hour (Nicotrol) period. While Habitrol and Prostep are prescription items in the United States, Nicotrol is sold over the counter. The four brands deliver nicotine at different rates and have different skin-contact effects (causing rashes or irritation in some users), but there is no evidence that any one brand is more effective than the others. There is as yet no way to tell which patch will work better for an individual patient.

The nicotine patch is highly effective: It doubles the rate of successful attempts to quit smoking. Different studies have reported that from 22 to 42 percent of patients quit after six months of using the patch. The success rate is higher when combined with counseling.

The University of Wisconsin's Center for Tobacco Research and Intervention suggests that patients may benefit from use of a skin patch if they have a strong desire to quit and fit into at least one of the following categories:

• smoke at least 20 cigarettes per day
• smoke their first cigarette within thirty minutes of waking up
• have experienced a strong craving for cigarettes during the first week of previous attempts at quitting

The nicotine patch should be applied as soon as the patient wakes up, and the user should stop all smoking during patch use. The patch should be applied to a hairless part of the body, with a different site every day. The same site should not be used again for one week. The recommended length of treatment for the four patches varies from six to sixteen weeks. Some researchers have concluded that, in general, the chances of success are better from longer-term use. Side effects include a skin reaction at the patch application site in 30 percent of patients. The patch may also cause some sleep problems, but these problems may actually be a symptom of the withdrawal rather than a side effect of the treatment.

Nasal Spray. A nicotine nasal spray (Nicotrol NS) is available only with a prescription. The spray is packaged in a pump bottle that smokers can inhale (up to eighty sprays per day) when they feel a craving to smoke. The spray can cause a person to become dependent on it (more so than with the patch or gum). For this reason, the manufacturer recommends that the spray be used for a maximum of three months. People with sinus conditions, allergies, or asthma should not use the spray, and it is not recommended for treatment of young smokers. Very heavy smokers may benefit from using the nasal spray in combination with the gum and skin patch.

Nicotine Inhaler. A nicotine inhaler (Nicotrol Inhaler) is also available only with a prescription. It contains nicotine mixed with menthol that is delivered to the mouth as a vapor. Most of the nicotine is absorbed through the mucous membranes of the mouth and throat, and does not get as far as the lungs. The most common side effects of the inhaler include a sore throat, irritation of the mouth, and coughing.

Non-Nicotine Medications

Medications that do not deliver nicotine are also sometimes used to treat nicotine addiction. Bupropion (Wellbutrin) is an antidepressant that reduces withdrawal symptoms and cravings to smoke. The most common side effects of bupropion are agitation and insomnia (inability to sleep), dry mouth, headache, nausea, and a skin rash. In studies, bupropion used together with a nicotine replacement helped 50 percent of a group of smokers to quit after one year of treatment. Buspirone (BuSpar) is an anti-anxiety medication that is used to help patients with tobacco withdrawal symptoms. It has a very low potential for abuse and does not interact with alcohol.

The Treatment of Nicotine Withdrawal

Clonidine (Catapres) is a medication that has been tried in the treatment of nicotine withdrawal discomfort. In studies, heavy smokers who took clonidine on days when they did not smoke found that it reduced anxiety, irritability, restlessness, tension, and craving for cigarettes. Researchers also gave clonidine to smokers trying to quit. After six months, 27 percent of those given clonidine reported that they did not smoke. Surprisingly, clonidine seemed to be effective only for women. Clonidine does have side effects, such as drowsiness, so doctors should recommend it with great caution.

Benzodiazepines. Nicotine strongly influences the smoker's mood. Smokers smoke more than usual during stressful situations. Therefore, those trying to quit often relapse (begin smoking again) during stressful situations. Treating the mood changes that result from abstinence may improve the chances of quitting smoking. In some extremely unusual circumstances, benzodiazepines (a type of tranquilizer) have been prescribed for this purpose. Because these drugs are extremely addictive, doctors only rarely resort to this treatment. More studies are needed to determine its effectiveness for treatment of smokers trying to quit.

Conclusions

Treatments that combine medications with behavioral approaches appear to have the best results. People smoke for different reasons (to prevent withdrawal, to ease anxiety, to relax, to achieve pleasant effects), so a treatment program that targets several reasons for smoking may be successful in most cases. Despite gaps in our knowledge, programs to quit smoking are improving constantly, and smokers do not have to be alone in their attempts to quit. The National Cancer Institute maintains a web site with constantly updated information about programs sponsored by a variety of organizations, including the American Cancer Society, the American Lung Association, and the Office on Smoking and Health of the Centers for Disease Control.

See Organizations of Interest at the back of Volume 3 for address, telephone, and URL.

see also Addiction: Concepts and Definitions; Nicotine; Tobacco: Dependence; Tobacco: Medical Complications; Tobacco Treatment: An Overview; Tobacco Treatment: Behavioral Approaches; Tolerance and Physical Dependence.