Nicotine replacement therapy (NRT) is for those who want to quit smoking, as abruptly quitting can cause withdrawals and cravings. Nicotine withdrawal occurs after suddenly discontinuing smoking cigarettes. Typical withdrawal symptoms include mood changes, diaphoresis, headaches, insomnia, and poor cognition. These symptoms usually peak at two to three days after quitting smoking. Using NRT helps one to reduce the motivation of smoking cigarettes because the body still gets nicotine from another safer method. Evidence has shown that using NRT helps increase the chances of quitting by about 50% to 70%. Withdrawals include restlessness, more than usual hunger, feeling depressed or irritable, and craving another cigarette.
Nicotine is an alkaloid and only produced in tobacco. It is a tertiary amine that has pyrrolidine and pyridine rings. It binds selectively to nicotinic-cholinergic receptors in multiple locations. The brain, neuromuscular junctions, adrenal medulla, and the ganglia all have these receptors. When a person inhales nicotine through smoking cigarettes, it diffuses through the lungs into the circulation, eventually going to the brain. It affects the reward center in the limbic system as well as having a stimulating effect in the cortex. Dopamine in the frontal cortex, mesolimbic area, and corpus striatum is released - dopamine helps deliver the pleasurable experience. NRTs try to mimic the nicotine response from smoking. Higher doses of NRTs will have more of a rewarding feeling, whereas lower doses of nicotine have more of a stimulating effect.
Forms of NRT do not need to be prescribed by a doctor; most are available over the counter. Patients should follow directions for each form of NRT. Even though there are different brands and forms, evidence shows no more significant effect of one type of NRT compared to another. Although some studies show that there is no benefit to using NRT for longer than eight weeks, others have found that longer duration of treatment with nicotine patch may be associated with improved smoking cessation rate. The initial dosing usually has its basis on the number of cigarettes smoked per day, and heavier smokers should use increased strength/dose of nicotine therapy. NRT products can be used if a patient is still smoking.
Patients should understand not to use two doses back to back. If the patient misses a dose, they should take it as soon as possible. If it is close to the time of the next dose, they can skip the missed dose.
The known adverse effects of nicotine include:
Patients should inform their physician immediately if any of the above side effects occur. Patients who worried about dependence should receive counsel that nicotine dependence is very rare.
Patients with cardiovascular or peripheral vascular disease should have the risks versus benefits weighed before deciding to start an NRT due to hypertension and increased heart rate side effects. Use caution when starting patients who have had angina or recent myocardial infarction. Discontinue if palpitations or irregular heartbeats occur.
The liver metabolizes nicotine. Therefore, swallowing pills through the gastrointestinal (GI) system will be subject to first-pass metabolism by the liver, and bioavailability would only be about 20%. This process will reduce the bioavailability of nicotine in the system and possibly cause side effects of the GI. Hence, the only available methods for nicotine are in a non-pill form such as a lozenge, sublingual tablets, transdermal patches, gum, inhaler, and sprays. These dose forms let the nicotine enter through the oral or nasal mucosa or skin and bypass the GI system for more extended bioavailability. The route of absorption is pH-dependent. Acidic foods and drinks can lower the absorption of nicotine. The skin patch releases nicotine at a slower rate. This controlled delivery makes toxicity from nicotine much less likely and prevents any GI side effects from happening. Symptoms in the rare event that the patient overdoses nicotine include nausea, vomiting, diarrhea, dizziness, difficulty breathing, tachycardia, weakness, or rash.
All healthcare workers have a responsibility for educating patients on the harms of smoking. The patient should be told about the nicotine replacement therapies currently available. Evidence has shown that using NRT helps increase the chances of quitting by about 50% to 70%. Withdrawals include restlessness, more than usual hunger, feeling depressed or irritable, and craving another cigarette. Bupropion is also an antidepressant with smoking cessation effects, and clinicians can combine it with the nicotine patch for a higher chance of success. These patients need continual support and positive reinforcement. Unfortunately, with all therapies, relapse rates are very high. [Level V]
|||Bellenguez Y,Chevalier F,Duhaut P,Colpart E,Dernoncourt A, [Smoking cessation in secondary prevention of acute coronary syndrome: The role of the electronic cigarette]. Annales de cardiologie et d'angeiologie. 2019 Jan 22; [PubMed PMID: 30683484]|
|||Lee LJ,Li Q,Bruno M,Emir B,Murphy B,Shah S,Reynolds M,Marchant N,Park PW, Healthcare Costs of Smokers Using Varenicline Versus Nicotine-Replacement Therapy Patch in the United States: Evidence from Real-World Practice. Advances in therapy. 2019 Feb; [PubMed PMID: 30569324]|
|||Kalkhoran S,Benowitz NL,Rigotti NA, Reprint of: Prevention and Treatment of Tobacco Use: JACC Health Promotion Series. Journal of the American College of Cardiology. 2018 Dec 11; [PubMed PMID: 30522631]|
|||Liberman K,Van Schuerbeek P,Herremans S,Meysman M,De Mey J,Buls N, The effect of nicotine patches on craving in the brain: A functional MRI study on heavy smokers. Medicine. 2018 Sep; [PubMed PMID: 30278517]|
|||Zhu J,Nelson K,Toth J,Muscat JE, Nicotine dependence as an independent risk factor for atherosclerosis in the National Lung Screening Trial. BMC public health. 2019 Jan 22; [PubMed PMID: 30669994]|
|||Loukas A,Marti CN,Perry CL, Trajectories of Tobacco and Nicotine Use Across Young Adulthood, Texas, 2014-2017. American journal of public health. 2019 Jan 24; [PubMed PMID: 30676800]|
|||Nethan ST,Sinha DN,Chandan K,Mehrotra R, Smokeless tobacco cessation interventions: A systematic review. The Indian journal of medical research. 2018 Oct; [PubMed PMID: 30666002]|
|||Livingstone-Banks J,Ordóñez-Mena JM,Hartmann-Boyce J, Print-based self-help interventions for smoking cessation. The Cochrane database of systematic reviews. 2019 Jan 9; [PubMed PMID: 30623970]|
|||Jackson SE,McGowan JA,Ubhi HK,Proudfoot H,Shahab L,Brown J,West R, Modelling continuous abstinence rates over time from clinical trials of pharmacological interventions for smoking cessation. Addiction (Abingdon, England). 2019 Jan 7; [PubMed PMID: 30614586]|
|||Frank Wolf M,Bar-Zeev Y,Solt I, [INTERVENTIONS FOR SUPPORTING WOMEN TO STOP SMOKING IN PREGNANCY]. Harefuah. 2018 Dec; [PubMed PMID: 30582312]|