Smoking and Tobacco Use

Chantix® is the first new medication approved for the treatment of tobacco addiction in over 10 years and it was specifically designed to simultaneously bind and block the nicotine receptors in the human brain. Chantix® is a prescription medication and must be prescribed by a physician or other licensed health professional. The effect of this tablet medication is to release the same pleasure neurochemical that nicotine stimulates while also preventing nicotine from having the same positive reinforcing effect on the smoker’s brain.  It helps the tobacco user’s brain think it is still smoking.

Simply stated, the smoker prescribed Chantix® does not get the same pleasure or “high” from their tobacco but also does not miss smoking as much. Research demonstrates that Chantix® allows the smoker to quit with greater ease. After 12 weeks of treatment, 44% of Chantix® users were tobacco free. As with all tobacco treatment medications, smokers who have difficulty establishing a quit date can focus on reducing their tobacco consumption without a specific planned quit date.

Approved by the FDA in 2006, there have been over 24 million Chantix® users worldwide. The most common side-effects are nausea, abdominal gas, constipation, insomnia and vivid dreams. Rare instances of depression have been reported. Many clinicians believe that this depression is most commonly due to nicotine withdrawal rather than Chantix® use but (uncommonly) it may be drug related. As we discussed previously, no medication is right for everyone. As always, discuss this and all medications with your physician. Your doctor or health care professional should be an integral part of your tobacco treatment plan.

In 1997, Bupropion, an antidepressant, was the first non-nicotine medication approved for the treatment of tobacco addiction. Years before, Dr. Linda Ferry observed at the Jerry L. Pettis Veterans Administration Hospital in Loma Linda, California that the Bupropion molecule was significantly more effective in helping her smoking military veterans quit. Every smoker, and those of us in the tobacco treatment field, owe Dr. Ferry a debt of gratitude.

In our experience, Bupropion tablets are particularly effective in smokers, who after stopping, experience depression, dysphoria or sadness. Bupropion is a prescription medication and must be prescribed by a physician or other licensed health professional. After years of using Bupropion, we observed and subsequently demonstrated in a large placebo-controlled multi-center study, that this medication reduces the amount of nicotine the smoker consumes prior to a quit date and even increases the motivation to quit.

Side-effects include dry-mouth, headache, constipation, light-headedness, and a reported one in 1,000 risk for a seizure. Like every medication, Bupropion is not right for every smoker. Talk to your physician to determine if Bupropion is a wise choice for you.

Bupropion works well with Chantix® and the nicotine replacement products. However, the correct use of multiple medications can require the assistance of a trained tobacco treatment specialist. Here is a listing of tobacco specialists in your area.

The Nicotine Nasal Spray delivers clean nicotine to the inside of the tobacco user’s nose. There, the nicotine is rather rapidly absorbed by the nasal mucus membranes (nasal mucosa) and delivered to the brain within 4 to 15 minutes. In fact, other than by smoking a cigarette, this is the fastest way to deliver nicotine to the brain. This makes the Nicotine Nasal Spray an extremely effective tobacco treatment. It can be used repeatedly and on a regular schedule as a “continuous” tobacco cessation medication and/or intermittently as a “rescue” medication for severe tobacco cravings. One spray of nicotine nasal spray to both nostrils delivers approximately the same amount of nicotine as the average smoker can receive from the average cigarette.

While the nasal spray can be irritating and can result in sneezing, runny nose, tearing eyes and less seldom an occasional bloody nose, these effects are usually minor and transient, easing or disappearing entirely after the nasal passages are acclimated to the spray. The ability to tolerate the nasal spray’s side effect is quite dependent on the technique used in the application.

For best results, first direct the spray towards the sides of each nostril, rather than the center, and allow the sprayed fluid to coat the inside of the nostril rather than straight up into the sinus. Hold your breath while spraying and after administration continue to breathe through your mouth for a few minutes and avoid sniffing the solution deep into the nose.

Nicotine Nasal Spray is a prescription medication. Talk to your doctor, healthcare professional, and tobacco treatment specialist to help determine if the nicotine nasal spray is right for you.

The nicotine inhaler is also a prescription medication. It consists of a nicotine gel cartridge, which is placed in a plastic tube vaguely resembling a cigarette. The nicotine gel releases a nicotine vapor, which is absorbed in the mouth’s oral mucous member. Each puff delivers approximately one-tenth the amount of nicotine delivered in a cigarette puff.

For some smokers, the cigarette shape and the use of the nicotine inhaler also helps in reducing tobacco cravings by simulating the hand to mouth ritual of smoking. Some users may experience a sore throat, nasal irritation, cough, heartburn, stomach upset, hiccups or nausea. The most common side effects being mild mouth or throat irritation and cough. These side effects are usually minor, do not occur for most users, and can be eliminated or minimized by correct use.

The nicotine inhaler, which is actually a puffer, should be puffed similar to a cigar so that the nicotine vapor is deposited onto the mouth’s lining. Nicotine is absorbed by the mouth’s lining rather than the lung so the most effective use of the nicotine inhaler is a series of shallow puffs. This also minimizes or eliminates side effects by avoiding inhaling the vapor into the back of the throat where it can irritate the vocal cords and the airways leading into the lungs.

The inhaler cartridges are designed to deliver the most nicotine at roughly four puffs per minute for 20 to 30 minutes and then discarding the cartridge. Most smokers puff each cartridge too infrequently and use, on average, between one and two cartridges per day. This is far too little to receive an adequate amount of therapeutic nicotine. For use as a “continuous” tobacco cessation medication, the FDA recommends using anywhere from 6 to 16 cartridges each day. The nicotine inhaler is also suitable for use as a “rescue” medication for severe tobacco cravings. Like all medications, correct use is essential for the desired therapeutic effect and increased quit rates.

In the United States, nicotine polacrilex gum was the first tobacco cessation medication ever approved by the FDA.  The gum is an over-the-counter medication that does not require a physician’s prescription and delivers nicotine in a resin matrix directly to the lining of the mouth, similar to the nicotine inhaler.

Nicotine gum is not like regular chewing gum. Chewed like ordinary gum, nicotine gum will not work very well. It is important to chew the nicotine gum very slowly until you notice a peppery taste or slight tingling sensation (usually after about 15 chews, but can vary individual to individual) in your mouth. Then “park” the gum between your cheek and gums (below your teeth line) until the peppery or tingling sensation disappears, then keep repeating these steps. One piece of gum that is chewed correctly can be used for about 30 minutes. Chewing incorrectly can increase unpleasant side effects such as heartburn. Do not eat or drink immediately before you use the gum.

Although the gum is available in 2 and 4 milligram strength, the consistency and flavors have improved significantly over the last two decades and is now available in mint, orange, cinnamon, fruit and other flavors.

Begin by chewing at least one piece every 1-2 hours. Side effects include mouth irritation, hiccups, nausea, and on rare, occasion jaw pain. The nicotine gum is contraindicated in smokers with TMJ (temporal mandible joint) syndrome or significant dental work or numerous missing teeth.

Like all FDA-approved medications, nicotine gum also significantly increases quit rates. It can be used frequently as a “continuous” tobacco cessation medication and/or intermittently as a “rescue” medication for severe tobacco cravings.

Nicotine polacrilex lozenges are an over-the-counter medication that does not require a physician’s prescription. Similar to the nicotine polacrilex gum, the nicotine polacrilex lozenge releases nicotine directly through the lining of the mouth, temporarily relieving craving and nicotine withdrawal symptoms. It is recommended to use one to two lozenges each hour and at least nine lozenges per day, but many smokers may need much more than this minimum.

Unlike ordinary lozenges, these are not meant to be chewed or swallowed. Place the lozenge in your mouth and allow the lozenge to dissolve slowly over 20 to 30 minutes while trying to swallow minimally. It is important to minimize swallowing so the dissolved medicine can be absorbed in the mouth. Of course, the lozenges deliver a lower, slower level of nicotine than a cigarette. It is not surprising that side effects are similar to the nicotine polacrilex gum and that it can be used frequently as a “continuous” tobacco cessation medication and/or intermittently as a “rescue” medication for severe tobacco cravings.

In the United States, the nicotine patch is an over-the-counter medication that does not require a physician’s prescription. Nicotine transdermal patches deliver a steady dose of nicotine directly through the skin. It works be entering the blood circulation and slowly entering the brain, easing craving and tobacco withdrawal symptoms and increasing quit rates.

A constant low dose of nicotine may be all that is needed to eliminate tobacco cravings in light smokers (e.g. five to six cigarettes per day). For those with heavier tobacco use and/or more severe cravings, the other nicotine products (spray, inhaler, gum or lozenge) can be used in addition as “rescue” medications for breakthrough cravings.

Some suggestions for proper application of the patch:

1. After a shower or cleaning a non-hairy area of skin with a non-moisturizing soap, let the area dry completely. The upper arm is a good choice for most people, but the patch can be worn on almost any non-hairy area. It is important to avoid using lotions, cream, and skincare products on the area you choose.
2. Try not to touch the sticky part of the patch while firmly pressing the patch on your skin with the heel of your palm for at least 10 seconds.
3. Wash your hands after applying or removing a transdermal nicotine patch.
4. Safely dispose of any foil pouch, wrapping in plastic that protected the patch. Used patches should be folded in half and disposed of safely as well. Make sure these materials are out of reach of children and pets.

The nicotine patch can be worn for either 16 (removed at bedtime) or 24 hours. If you crave cigarettes when you wake up or feel like you want extra protection from tobacco cravings, wear the patch for 24 hours. Some patients can experience vivid dreams while wearing the patch after bedtime. In actuality, some patients enjoy the vivid colorful dreams. If vivid dreams present a problem, simply remove the patch at bedtime and apply a fresh patch first thing in the morning.

Some smokers experience skin irritation caused by the adhesive. This can often be effectively treated with over-the-counter cortisone cream. Cortisone cream can be applied after the patch is removed. In more severe instances the area can be pre-treated the night before but, wash off the area of the remaining pre-treatment cortisone cream before applying the patch in the morning. Some patients may prefer one brand to another because of differences, real or perceived in effectiveness, stickiness and/or skin irritation.