Latest Guidance On Use Of Nicotine Replacement Therapies

Guidance For Smokers on Use of Nicotine Replacement Therapy Nicotine replacement therapy (NRT) includes a number of over-the-counter medications that are safe and effective for helping smokers to quit. These include the nicotine patch, nicotine gum and the nicotine lozenge. However NRT is underused by smokers trying to quit, and particularly is underused by Latino smokers. There are many reasons for this, but part of this is that smokers have misconceptions about how to use these medicines. In order to remedy this situation, a group of experts on smoking cessation has published a paper containing advice for smokers on how to use over-the-counter nicotine replacement therapies as an aid to smoking cessation. This includes a single-page summary of 11 key pieces of advice.

We are grateful to Lynn Kozlowski (University of Buffalo) and to Elsevier Publications Inc. (publishers of Addictive Behaviors), for permission to provide a version of the full published paper, a single page summary of the advice (in English) and also a Spanish translation of the key advice for patients.

The Spanish translation of the key advice is available at: http://proyectovidanofume.org/espanol/indexspan.htm.

Please note that the citation for the paper is:

Kozlowski LT, .Giovino GA, Edwards B, DiFranza J, Foulds J, Hurt R, Niaura R, Sachs DPL., Selby P, Dollar KM., Bowen D Cummings KM, Counts M, Fox B, Sweanor D, Ahern F. Advice on using over-the-counter nicotine replacement therapy- patch, gum, or lozenge- to quit smoking. Addictive Behaviors (in press).

Both the project run by Professor Kozlowski and the translation into Spanish were funded by grants from the Robert Wood Johnson Foundation. Jonathan Foulds PhD Director, Tobacco Dependence Program at UMDNJ-School of Public Health, P.I., Proyecto Vida: Latino Deje de Fumar

Summary Statement to Consumers on Use of Nicotine Gum, Patch and Lozenge: Over-the-Counter Nicotine Replacement Therapies

1. NRT is one good tool to help you quit smoking. But NRT can’t do all the work for you—you have to help—and it is not the only tool to help you stop smoking.

2. Don’t worry about the safety of using NRT to stop smoking: NRT is a safe alternative to cigarettes for smokers.

3. Do be cautious about using NRT while pregnant.

4. NRT is less addictive than cigarettes and it is not creating a new addiction

5. Stop using NRT only when you feel very sure you can stay off cigarettes.

6. If the amounts of NRT you are taking do not help you stop smoking, talk with your health care provider about using (1) more NRT, (2) more than one type of NRT at the same time, (3) other smoking cessation medicines at the same time, or (4) telephone or in person advice on quitting tips.

7. If NRT helps you stop smoking, but you go back to smoking when you stop using NRT, you should seriously think about using NRT again the next time you try to stop smoking.

8. Make sure you are using the gum or lozenge in the best way:

o Chew the gum slowly – fast chewing doesn’t allow the nicotine to be absorbed from the lining of the mouth and can cause nausea.

o Don’t drink anything for 15 minutes before and nothing while you are using nicotine gum or the lozenge so your mouth can absorb the nicotine.

o Make sure you get the right amount of nicotine – people who smoke more than 10 cigarettes per day should use a 4mg piece of gum or lozenge.

9. Make sure you are using the patch in the best way:

o If you can’t stop having a few cigarettes while using the patch, it is best to keep the patch on. Don’t let a few slips with cigarettes stop you from using the patch to quit smoking.

o You may need to add nicotine gum or lozenges to help get over the hump or you may need to use more than one patch at a time. Talk to your healthcare provider about this.

10. If the price of NRT is a concern, try to find “store brand” (generic) NRT products which are often cheaper than the brand name products.

11. Do whatever it takes to get the job done—it is not a weakness to use medicine to stop smoking.

Adapted from: Kozlowski LT, .Giovino GA, Edwards B, DiFranza J, Foulds J, Hurt R, Niaura R, Sachs DPL., Selby P, Dollar KM., Bowen D Cummings KM, Counts M, Fox B, Sweanor D, Ahern F. Advice on using over-the-counter nicotine replacement therapy- patch, gum, or lozenge- to quit smoking. Addictive Behaviors (in press).

Additional Information For Consumers on Use of Nicotine Gum, Patch and Lozenge: Over-the-Counter Nicotine Replacement Therapies

“NRT” is Nicotine Replacement Therapy for helping tobacco users quit. NRT products include the nicotine patch, gum and lozenge, and these products are sold “over-the-counter” (OTC) without a healthcare provider's prescription. The nicotine in these products replaces, to some degree, the nicotine from cigarettes in a safe form to help smokers stop smoking. Reading NRT package labels and inserts gives important information about what it is and how it works. The makers of NRT are under strict rules on what can and cannot be written on the NRT label about how to use NRT. If you are thinking about using NRT, you probably have some questions and an expert may not be on hand to answer them. To help smokers get all the answers they need, a group of smoking research experts and clinical experts wrote this statement containing some of the most helpful and important facts you need to know about using NRT. This statement has not been approved by the FDA (Food and Drug Administration) or by any other regulatory agency; but it does represent the judgment of research and clinical experts. If you are able to consult with your health care provider on these issues, we advise that you do so, knowing that there are some NRT products and other tobacco cessation products available only by prescription.

1. NRT is one good tool to help you quit smoking. But NRT can't do all the work for you—you have to help—and it is not the only tool to help you stop smoking.

You could be disappointed if you think using NRT or anything else will make quitting smoking easy. But using NRT could make quitting easier by reducing your cravings or the bad feelings you have when you stop smoking. Like other tools, NRT can help you—if you are also willing to put some work into it. Not everyone will find NRT helpful. Keep in mind that there are other tools available for stopping smoking. You can try other NRT's by prescription such as the oral inhaler and the nasal spray or non-nicotine medications in tablet form such as buproprion or Varenicline (Chantix). You also can talk to your health care provider, call your state telephone quit-line, or call 1-800-QUITNOW for tips on quitting.

2. Don't worry about the safety of using NRT to stop smoking:

NRT is a safe alternative to cigarettes for smokers. Studies show that NRT is a safe alternative to cigarettes for smokers, and DOES NOT cause cancer or heart attacks, even for smokers who already have had heart attacks or heart disease. Also, nicotine is not the really dangerous chemical in cigarettes. Cigarette smoke contains many harmful chemicals, and it is these, not nicotine, that are responsible for the heart attacks, cancer, and lung disease. The risks of cigarette smoking are much greater than the risks of NRT. Cigarette smoking causes suffering (such as breathlessness, difficult breathing or pain from cancer or heart disease) and, in the end, can cause early death in half of long-term smokers. NRT has been found to be very safe for nearly every user, yet some smokers and even some health care workers have mistaken health concerns about NRT. Some people think that the nicotine patch is dangerous for heart patients, but this is not true. Nicotine and thus NRT does not cause cancer, but some recent studies suggest that it might be better for those who are undergoing treatment for cancer to stop smoking without using NRT. Those diagnosed with cancer should talk with their doctor about whether they should prefer using an FDA approved non-nicotine stop smoking medication (e.g., buproprion [Zyban] or varenicline [Chantix] over NRT.

If you have just had some serious new heart or heart-related problem (for example, heart attack or stroke) within the past 4 weeks, NRT is likely safe to use at that time, but, under these circumstances, you should talk with your health care provider about taking this or any medication. Cigarettes should clearly be avoided just after a heart problem, and NRT, especially the short-acting gum or lozenge, has been used to help individuals with recent heart problems who are having trouble staying off cigarettes. Know that cigarette smoking is very dangerous compared to NRT and you should be avoiding smoking. For those who have not just had a new heart problem and have longer-term heart problems, NRT has been found to be safe to use.

NRT packages come with many warnings and directions that can lead a person to believe that NRT is far more risky than it actually is. It is a mistake to think that any NRT product is as dangerous as cigarettes. NRT does not kill, it saves lives!

3. Do be cautious about using NRT while pregnant.

Some studies suggest that pregnant women should try to stop smoking WITHOUT the use of NRT, if they can. It is very important for the health of the unborn baby to stop smoking cigarettes. If you can quit smoking without NRT, that is great. If you believe that you need NRT to stop smoking during pregnancy, talk to your health care provider; it may still be useful to get you off cigarettes. After the birth of the child, it is still very important for a mother not to smoke, and for NO ONE to smoke around the child.

4. NRT is less addictive than cigarettes and it is not creating a new addiction.

Some smokers worry about becoming addicted to NRT or becoming ‘hooked on’ the gum, lozenge, or patch. While it is true that the nicotine in NRT products is addictive, smokers are already addicted to nicotine—they get a lot more of it from each cigarette they smoke than from any NRT product. Smokers usually do not get as much nicotine from NRTs as from cigarettes, nor do they find NRT as enjoyable to use as cigarettes. This is because breathing in smoke through the lungs gives the brain a rush of nicotine while NRT gives nicotine more slowly through the skin or lining of the mouth. In fact, most smokers don't use enough NRT to get all the help they could to stop smoking. While some smokers could find it hard to stop using NRTs because of the nicotine in these products, there are two important things to remember: first, even using a NRT for a very long time is much less harmful to health than smoking for the same amount of time; second, stopping an NRT is not likely to be as hard as stopping smoking.

5. So, how long should you use NRT?

NRT product labels say that the product should be used for 8 or 12 weeks, depending on the product. For some smokers, this is enough time to stop smoking for good. Some smokers do not need to use NRT that long to stop smoking. Other smokers may need to use NRT for several months or even years to stay off cigarettes. If NRT is helping you not smoke, we suggest you do not even think about cutting down on it unless (a) you believe you have a side-effect from NRT or (b) you have 14 days in a row with no cravings or withdrawal or near slips back to smoking. Using NRT longer than 8 to 12 weeks is not dangerous. Going back to cigarettes is very dangerous and could kill you! In fact, it is a common problem with NRT, that people don't even use it for the whole recommended 8–12 week period. We suggest you stop using NRT only when you feel very sure you can stay off cigarettes. If it ever comes down to a choice of using NRT or returning to smoking, stay on the NRT. A good rule of thumb is that if you are able to easily resist smoking without any cravings in situations that would have made you smoke in the past, you are ready to stop the NRT.

6. If the amounts of NRT you are taking do not help you stop smoking, talk with your health care provider about using (1) more NRT, (2) more than one type of NRT at the same time, (3) other smoking cessation medicines at the same time, or (4) telephone or in person advice on quitting tips.

Even though the NRT packages say you should not use more than one NRT, most experts agree that, for some smokers, using more than one type of NRT product at the same time can be helpful in stopping smoking and is safe. The patch, for example, gets nicotine to your brain very slowly but does so for many hours. Nicotine gum and lozenge get nicotine to your brain faster than the patch (but not as fast as cigarettes) but they deliver nicotine for short periods of time. Nicotine gum or lozenge can be useful to increase nicotine levels at those times when it is very hard to keep from smoking while using the patch alone. Instead of smoking a cigarette when you are wearing the patch, try a piece of the nicotine gum or the lozenge to get over the urge first. These urges to smoke do not last very long. In using more than one NRT product at the same time, pay attention to how you are feeling—your own reactions can be a guide to whether you are getting too little nicotine or overdoing it. Prescription smoking cessation medicines can be used with NRT; but you need to talk with a health care provider about a prescription and whether using that medicine with NRT is a good idea for you.

7. If NRT helps you stop smoking, but you go back to smoking when you stop using NRT, you should seriously think about using NRT again the next time you try to stop smoking.

Many medicines need to be used over and over again to deal with health problems that do not go away completely. For problems like asthma, diabetes, and high blood pressure, medicine often needs to be taken for a long time—not just a few weeks. Just as an asthma medication that helped an asthma attack before is likely to help again, NRT is likely help a smoker stop again if it was helpful before.

Some smokers keep going back to cigarettes after quitting for a time. If that happens to you, you should try to stop smoking again as soon as you can and use ways or tools that helped you quit before. If NRT helped you stay off cigarettes, even for a few days, definitely think about using it again. New NRTs that work better and are more appealing may be available since the last time you quit. If NRT use was not that helpful to you, look for other ways to quit smoking but make sure you were using enough NRT and used it in the best way the first time before you give up on it.

8. Make sure you are using the gum or lozenge in the best way:

• Park the gum between your teeth for 2–3 min between chews — fast chewing does not allow the nicotine to be absorbed from the lining of the mouth and can cause nausea.

• Do not drink anything (including coffee, orange juice, beer, wine, or sodas) for at least 15 min before and nothing while using nicotine gum or lozenge, so your mouth can absorb the nicotine.

• Make sure you get the right amount of nicotine — people who smoke more than 10 cigarettes per day should use a 4 mg piece of gum or lozenge.

9. Make sure you are using the patch in the best way:

• If you can't stop having a few cigarettes while using the patch, it is best to keep the patch on. Do not let a few slips with cigarettes stop you from using the patch to quit smoking.

• You may need to add nicotine gum or lozenges to help get over the hump or you may need to use more than one patch at a time. Talk to your healthcare provider about this.

10. The cost of NRT.

If the price of NRT is a concern, try to find “store brand” (generic) NRT products which are often cheaper than the brand name products. There is no reason to think that brand name NRT works better than store brands. And keep in mind how much cigarettes cost. Putting your cigarette money toward NRT can in the long run save you a lifetime of cigarette money. And if you can find the money for cigarettes, you probably can find the money for NRT. Think about buying NRT over the Internet. It is legal to do so and can be cheaper. Some health benefit plans, including some Medicaid providers, pay for NRT, and some state Health Departments and telephone quitlines provide NRT at no cost if you engage in the telephone counseling.

11. Do whatever it takes to get the job done—it is not a weakness to use medicine to stop smoking.

Some people think that if you really want to quit smoking, you should be able to just do it without any help. While it is true that not everyone “needs” medicine to stop smoking, it is also true that not everyone needs medicine to treat asthma, diabetes, or high blood pressure. NRT is only one tool that can help in the hard job of stopping smoking. Those who quit smoking with or without NRT are both making the same smart move for their health—they are becoming ex-smokers.

Levels of addiction vary, and what life throws at you varies from person to person. Maybe one person had an easier time quitting because they were not living or working with other smokers. Maybe one person had a harder time because they had other problems (stress) to deal with. You are not competing with other smokers, you are competing against your cigarettes. If you find NRT helpful and you need to use it for a long time to stay off cigarettes, do not be disappointed or worried—be proud of yourself because you have stopped smoking.

The most important thing about quitting is to stop using cigarettes—it does not mean you are a “better person” with a “stronger will” if you try to quit smoking without using medicine or other help.