Breaking Free From Nicotine Dependence

Harvard Health

More than 46 million adults in the United States smoke cigarettes, cigars, or pipes, and a few million use snuff or chewing tobacco. Although 70 percent of smokers say they'd like to stop, nicotine is so addictive that only 3 percent successfully quit each year.

Smoking sends nicotine straight to the lungs, where it's absorbed by oxygenated blood, delivered to the heart, and pumped into the arteries and the brain. The nicotine in snuff and chewing tobacco, which is absorbed mainly through the mucous membranes of the mouth, reaches the brain more slowly, but constant use maintains a steady level in the blood and brain.

Once in the brain, nicotine triggers the release of the neurotransmitter dopamine in the nucleus accumbens, which is the brain's reward and motivation center. Each hit of nicotine produces pleasurable feelings. But as it gets washed out of the body, the feelings of pleasure are replaced by uncomfortable symptoms of withdrawal -- trouble concentrating, nervousness, headaches, increased appetite, dizziness, irritability, anxiety, depression, and sleeping problems. This prompts most users to reach for more tobacco.

The reasons for quitting are familiar but worth restating. Tobacco accounts for about one in five deaths in the U.S. For every smoking-related death, 20 more people suffer from at least one serious smoking-related illness, including cancer, heart disease, stroke, and lung diseases. The risk of these illnesses and other smoking-related health problems drops significantly for those who quit.

Since 1965, the number of smokers in the U.S. has declined by more than 50 percent. But despite general understanding of the harmful effects of tobacco and current policies restricting access to it, that trend is weakening. The U.S. Centers for Disease Control and Prevention estimates that every day, nearly 3,000 adolescents and adults begin smoking on a daily basis.

For people who want to stop using tobacco, two hurdles must be jumped: overcoming the physical addiction to nicotine and breaking the psychological habit.

Nicotine Replacement Therapy

Nicotine replacement therapy (NRT) is a common strategy for managing the physical addiction, giving the brain the nicotine it demands without exposure to hundreds of other harmful substances in cigarette smoke. And, with relief from withdrawal symptoms, users can try to free themselves of the tobacco habit. Compared to cigarettes, NRT supplies a lower dose of nicotine, which is absorbed more slowly and reaches a lower, but steadier, level in the blood and brain.

A variety of NRT products approved by the U.S. Food and Drug Administration are available. Although results vary, many controlled studies indicate that consistent use of NRT increases the chances of quitting by 50 percent to 70 percent. Among the choices:

Nicotine patch.

Available over the counter, the patch supplies a low dose of nicotine that gets absorbed by the bloodstream throughout the day. On the planned "quit day," the smoker applies a nicotine patch to a hairless spot on the upper arm or torso. A typical patch is worn for 16 or 24 hours, depending on the person's needs, then replaced.

Most people should use the patch for eight weeks. The major side effect is skin irritation at the site. (This can be prevented by applying the patch to different spots.) A too-high nicotine dose can cause racing heartbeat, sleep problems, and headache.

Nicotine gum.

Nicotine gum is also available without a prescription. When chewed, it releases a low dose of nicotine that passes into the bloodstream through the lining of the mouth. It may be easier for a user to regulate the dose of nicotine with gum than with a patch.

People chew the gum a few times to release nicotine. Then they place it between their gums and cheek. The nicotine is absorbed over about 20 minutes, and people usually discard the gum after 30 minutes.

Many clinicians recommend chewing at least one piece of gum every one to two hours while awake, for one to three months. People using nicotine gum often chew too few pieces per day and for too few weeks to receive its maximum benefits.

Side effects include hiccups, upset stomach, a sore jaw, or a burning sensation in the mouth. This may result from not chewing the gum as directed. To avoid becoming dependent on nicotine gum, people should use it for six months or less and reduce use gradually.

Nicotine lozenges.

Like nicotine patches and gum, lozenges are available without a prescription. They supply a low dose of nicotine to reduce symptoms of nicotine withdrawal. People suck on a lozenge every hour or two during the day, or as needed. This product may cause upset stomach.

Nicotine nasal spray.

The nicotine in a prescription-only nasal spray reaches the bloodstream within five to 10 minutes. Relief of withdrawal symptoms is relatively fast, but there's a higher potential for dependency than with other nicotine products.

It's generally recommended that patients use the spray at least eight times a day to ensure that they receive an adequate dose of medication. Side effects include nose and throat irritation, watery eyes, sneezing, coughing, diarrhea, and rapid heartbeat. Nicotine nasal spray is not recommended for people with asthma or chronic sinusitis.

Nicotine inhaler.

Cigarette-shaped medication cartridges, available by prescription, supply low-dose nicotine through the mouth, throat, and lungs as people puff. They can be used whenever there's an urge for a cigarette. The nicotine level peaks in about 20 minutes and stays in the blood for one to two hours. The standard dose is up to 16 cartridges per day, for up to 12 weeks. Side effects include coughing and mouth and throat irritation. Using cartridges may be too much like smoking to help the user break the habit.

High-dose or combination therapy.

People who are heavy smokers might need a higher dose of NRT to get relief. For this group, combining a long-lasting product, like a patch, with a fast-acting product, like nicotine gum, may be more effective than a single form of NRT.

NON-NICOTINE PILLS

Some medications used for quitting smoking don't release nicotine into the bloodstream. Instead, they act on the brain to decrease cravings, withdrawal symptoms, or both.

Varenicline (Chantix).

This prescription drug works in two ways. It mimics the effects of nicotine, cutting down cravings and withdrawal symptoms. It also partially blocks nicotine's effect, causing a smoker to get less of a reward. It's not meant to be used with NRT, though some studies have shown that the two therapies might be safely combined.

People usually start taking varenicline a week or two before they quit, giving it time to reach a steady level in the bloodstream. Varenicline is generally taken for 12 weeks, but some clinicians may prescribe it for longer, provided there are no adverse effects.

The most serious potential side effects of varenicline are psychological, including agitation, depression, suicidal thinking, and vivid, unusual dreams. Any nausea is usually mild and improves over time. Other common side effects include headache, vomiting, gas, insomnia, and changes in taste.

Bupropion (Wellbutrin, Zyban).

This prescription antidepressant helps reduce the desire to smoke by triggering some of the same receptors as nicotine. Because it doesn't contain nicotine, it can be used in combination with NRT.

A smoker should start taking bupropion one to two weeks before his or her planned quit day and continue taking it for eight to 12 weeks. It takes three to four weeks for the drug to reach its maximum effectiveness.

Side effects of bupropion may include the same psychological changes that can occur with varenicline. Other potential side effects: insomnia, anxiety, dry mouth, change in appetite, headache, diarrhea, dizziness, and skin rash.

More serious side effects can occur in people with a seizure disorder. Bupropion is not recommended for people with a history of seizures, anorexia, heavy alcohol use, or head trauma.

In July 2009, the FDA required the makers of varenicline and bupropion to put "black box" warnings on the packaging of these drugs, alerting people about the possibility of dangerous psychological side effects, including changes in behavior, hostility, agitation, depression, and suicidal thoughts or behavior.

Vaccines.

Researchers are testing anti-smoking vaccines that "immunize" smokers against the nicotine "high." After getting the vaccine, the body produces antibodies that bind to nicotine, preventing it from leaving the blood and entering the brain. This limits nicotine's effect on the brain. The hope is that without the effect, people won't enjoy smoking and will be able to quit. This is similar to the way the stop-smoking prescription medicine varenicline (Chantix) works.

A handful of small trials suggest that vaccines may be effective, and larger trials are under way. How these investigational vaccines compare to NRTs remains to be seen.

PSYCHOTHERAPY AND SELF-HELP PROGRAMS

Most treatment programs use behavioral and cognitive techniques to help smokers quit. The aim of behavioral therapy is to change the stimulus and response patterns that cause smoking (classical conditioning), or to reward patients for not smoking and teach them how to avoid it (operant conditioning and social learning). Patients are urged to find other ways to meet the needs served by smoking and taught to monitor themselves for cues that provoke it.

Training in social skills, problem-solving strategies, stress management, and relapse prevention helps them cope with temptation. They learn to keep their hands and mouths otherwise occupied, distract themselves with exercise, or practice relaxation in response to the urge to smoke. They may also have to avoid alcohol, since a third of relapses occur while drinking.

Some smokers can quit by resisting the urge while repeatedly putting themselves in situations that provoke it -- a technique known as exposure therapy. Others find it easier to quit when the usual circumstances associated with lighting up are absent. In aversive therapy, a rare and doubtfully effective treatment, rapid and deep smoking is used to associate tobacco with unpleasant sensations like nausea and dizziness. Another behavioral technique is contingency management -- a deposit of money or other valuables that is refunded or forfeited depending on whether the patient succeeds in abstaining.

Cognitive therapy teaches patients to cope with frustration, anger, and depression, recall their reasons for quitting when resolve weakens, and avoid falling into despair because of a lapse. Developing a feeling of self-efficacy, or confidence in the ability to achieve what one wants, may prevent the loss of control and catastrophic discouragement that turn a slip into a permanent relapse.

The average rate of abstinence six months after cognitive-behavioral treatment is 20 percent to 25 percent, or twice the success rate of patients assigned to a waiting list. Research shows that effectiveness of counseling increases with intensity. There is little difference between various types of treatment or between individual and group therapy. Studies have shown that telephone quit-line counseling, with its broad reach, is also effective at stemming tobacco use across diverse populations. One analysis found that three or more phone calls increases the odds of quitting for at least six months compared with providing standard self-help materials or brief advice.

Although medication and counseling are effective when used individually for treating tobacco dependence, evidence shows that the combination is more effective than either one alone. One study found that the most successful quitters were those who used the greatest number of strategies. That's why many experts -- and American guidelines for the treatment of tobacco dependence -- recommend a combination of medication and counseling. - Harvard Mental Health Letter

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