Nicotine replacement therapy (NRT) is for those who want to quit smoking, as quitting abruptly can cause withdrawals and cravings. Nicotine withdrawal occurs after smoking cigarettes is suddenly discontinued. 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, which is 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 nicotine is inhaled 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 is linked to delivering 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. Directions should be followed for each form of NRT. Even though there are different brands and forms, evidence shows no greater effectiveness of one type of NRT compared to another. Studies also show that there is no benefit for using NRTs longer than eight weeks. Heavier smokers should use increased strength/dose of nicotine therapy.
Do not use 2 doses back to back. If a dose is missed, take it as soon as possible. If it is close to the time of the next dose, skip the missed dose.
Known adverse effects of nicotine include headaches, depression, back pain, and dizziness. Others include nervousness, drooling, shakiness, cold sweats, diarrhea, hypertension, increased heart rate, and vivid dreams.
Inform a doctor immediately if any of the above side effects occur.
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 get first pass metabolism by the liver, and bioavailability would only be about 20%. This 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. This lets the nicotine enter through the oral or nasal mucosa, or skin and bypass the GI system for longer 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 makes toxicity from nicotine much less likely and prevents any GI side effects from happening. Symptoms in the rare event that nicotine is overdosed, 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 can be combined 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)
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