July 25, 2014
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Quitting smoking medications

Medications are not the silver bullet, but they might help!

Smoking addiction is a complex issue with physical, psychological, social, and even spiritual components. A pill, a patch, or a piece of gum is not going to miraculously fix an addiction that is woven throughout every aspect of your life, but medications can help reduce cravings and withdrawal symptoms during the first weeks to months of smoking cessation.

Medications available in Canada to help with quitting smoking include:

  • nicotine replacement therapy (gum, patches, lozenge, inhaler)
  • bupropion (Zyban®)
  • varenicline (Champix®)

Ideally, medication therapy could:

  • provide stable brain nicotine levels, avoiding the roller-coaster intoxication-withdrawal cycles
  • allow for gradual reduction of nicotine so you gradually adapt, develop effective coping skills to deal with cravings, and learn effective relapse-prevention techniques
  • help avoid or lessen the emotional "crash" of withdrawal
  • help with the physical symptoms of acute withdrawal, such as irritability and anxiety

Comparisons of various methods of quitting have shown the following success rates at 6 months following attempts at smoking cessation:

Method Percentage of people still smoke-free at 6 months*
cold turkey 3-8
counselling 12-18
assistance by family doctor (4 visits min.) 13-20
counselling plus nicotine gum 19-25
counselling plus nicotine lozenge 20-24
counselling plus nicotine patch 20-31
counselling plus bupropion pill 30-35
counselling plus patch and bupropion 35-42
counselling plus varenicline pill 22-44

*Composite results from many studies using different outcome measures.

Gum and lozenge

Many of the adverse effects associated with nicotine come from tobacco smoke. The other problem with smoking a drug is how quickly the nicotine starts to work on the brain and how short-lasting the effects are of the drug. This results in a constant cycle throughout the day, from withdrawal to intoxication to comfort to withdrawal, as a person smokes a cigarette.

Nicotine gum is a nicotine replacement therapy, which provides a delivery system that allows you to decide on the needed dose. If craving occurs, you chew on the gum by biting it once or twice, then "park it" between your cheek and gum, then wait a minute and repeat. If you start to feel dizzy, slow down. The released nicotine is absorbed directly through the tissues of the mouth. Similarly, a nicotine lozenge can be dissolved in the mouth slowly when a craving occurs, delivering controlled amounts of nicotine over 20 to 30 minutes.

Swallowing the gum or even saliva containing nicotine will not result in effective delivery of nicotine to the brain. This is because the nicotine needs to be in an environment with an appropriate pH (acidity) level. The acidic environment of the stomach blocks the nicotine from being absorbed by the body. However, the mouth is less acidic (has a higher pH) and is an effective environment for absorbing nicotine.

Nicotine gum and lozenges come in several strengths. More heavily addicted smokers might prefer higher doses, and once they are smoke-free for several weeks they can switch to a lower dose and gradually wean themselves from the medication. Your doctor or pharmacist can help you determine the dose that is best for you.

Nicotine replacement therapy starts once you stop smoking (i.e., on your quit date). The idea of nicotine replacement therapy is to stabilize brain chemistry, stop the craving - drug-seeking - reward - relief cycle, and allow you to make lasting behavioural changes. Then the amount of gum or lozenge used can be decreased and you can deal with withdrawal in a gradual way.

While using nicotine gum or lozenges, avoid acidic drinks (e.g., coffee, fruit juice) for 15 minutes before and while using them. Side effects from the gum and lozenge include nausea and indigestion. Some people complain about the taste of the gum.

In general, most people can use nicotine gum or lozenges, but consult your health care provider if you have any medical conditions, such as heart problems.

Patch

The nicotine patch is another form of nicotine replacement therapy. More and more medications are successfully delivered by applying them to the skin. Any area of skin free from hair makes a suitable site for administration of the nicotine patch. It's usually applied to the upper arm, front or side of the chest, or hip. Several brands of the nicotine patch are available, each offering a variety of dosage forms. Some patches are taken off at night (16-hour dosing) and some are worn 24 hours per day. Treatment with the patch usually lasts for 3 months.

When combined with counselling, both the patch and the gum have been shown to result in twice the rates of successful quitting at 6 months when compared to the effect of counselling and taking a placebo.

Some people find the patch causes irritation or a rash at the site of application. The patch can also cause unusual dreams when worn during the night.

In general, most people can use the nicotine patch, but consult your health care provider if you have any medical conditions, such as heart problems.

Nicotine inhaler

Nicotine inhalers offer alternative methods of nicotine delivery. They have been shown to be effective in helping smokers through the early phases of quitting smoking. Nicotine inhalers also allow you to continue the hand-to-mouth smoking motion for as long as you need.

As you breathe through the inhaler, your body absorbs the nicotine from the inhaler through the linings in your mouth and throat. Common side effects can include throat or mouth irritation, headache, or upset stomach. In general, most people can use a nicotine inhaler, but consult your health care provider if you have any medical conditions, such as heart problems.

Nicotine mouth spray

Nicotine mouth sprays also offer alternative methods of nicotine delivery. These products provide relief and prevention of nicotine craving and the withdrawal symptoms associated with tobacco use. Nicotine mouth sprays help you to reduce prior to quitting, and provide a safer alternative to smoking for smokers and people around them.

As you administer 1 or 2 sprays in your mouth, your body absorbs the nicotine from the inhaler through the linings in your mouth and throat. Common side effects can include throat or mouth irritation, headache, or upset stomach. In general, most people can use nicotine mouth spray, but consult your health care provider if you have any medical conditions, such as heart problems.

Bupropion

This prescription medication comes in pill form and was first developed as an antidepressant medication. It works via the neurotransmitters (chemical messengers) dopamine and norepinephrine, two of the neurotransmitters affected by nicotine addiction. By maintaining adequate levels of dopamine at the "reward" part of the brain and blocking some of the withdrawal symptoms, the medication helps people avoid some of the craving, irritability, and anxiety that often marks the early days of being smoke-free. The increased appetite and resulting weight gain that are common in the early stages of quitting smoking are less likely to occur with this medication.

Usually the doctor will instruct you to proceed with preparations to quit and to take the medication for about 7 to 10 days before the quit date. Starting the medication before the quit date allows the medication to begin to work before you stop smoking (and nicotine is withdrawn).

Side effects consisting of nausea, irritability, and headache usually go away. People on other antidepressants must discuss with their doctor whether or not this medication will be safe for them. Bupropion should not be taken if you have a history of a seizure disorder or have an eating disorder.

Varenicline

This prescription medication comes in pill form and is thought to work to reduce the sense of pleasure derived from smoking by blocking nicotine's effect in the brain. It should be used in combination with counselling. It also helps with cravings and withdrawal symptoms. Varenicline should not be used in combination with nicotine replacement therapy because of the increased risk of side effects.

Common side effects include nausea, vomiting, headache, difficulty sleeping, abnormal dreams, constipation, and gas. If you have depression or other mental health issues, you should discuss with your doctor whether or not this medication is appropriate for you. Some people taking varenicline have experienced mood and behaviour changes (e.g., agitation, hostility, feeling depressed).If you experience mood or behaviour changes while taking varenicline, contact your doctor immediately. Taking this medication on a full stomach can reduce the side effect of nausea.

Unlike nicotine replacement therapy, varenicline is given while you are still smoking, with your quit date occurring 8 to 14 days after you start the medication.

If you are planning to quit smoking, talk to your doctor about whether medication might help you. Which medication you use will depend on your preferences and on your medical history.

 
Written and reviewed by the MediResource Clinical Team

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