Treating Tobacco Use

Wellness Education Unit

It’s Your Life Health Management Program

Prevention and Community Health

(517) 780-7306

Last Reviewed 5/2015

In 2014, 50 years after the first Surgeon General’s Report on smoking, 18% of American adults smoke, or nearly 1 in 5 adults and teenagers currently smoke, compared to 42% in 1964. More than half of all smokers have already quit. Today there are many ways to conquer nicotine addiction.

People who talk to their physicians about quitting or call quit lines are more successful than those who quit cold turkey. Using FDA-approved medications and nicotine patches, gum or lozenges, along with coaching support can double the chances of success.

“There is no safe level of exposure to tobacco smoke. Quitting tobacco is the most important thing you can do to protect your health.” This module will provide you with information that will help you succeed.

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Nicotine

Tobacco smoke and chew contains nicotine, a stimulant that temporarily improves alertness and memory, but also forms a strong physical and psychological chemical dependence (addiction). Tobacco users must overcome both of these addictions if they want to become tobacco free.

Nicotine affects your whole body, including your heart and blood vessels, your hormonal system, your metabolism, and your brain. Once inhaled or chewed is absorbed into the bloodstream and your heart pumps nicotine to your brain and the rest of your. During pregnancy nicotine can be found in breast milk, and freely crosses the placenta to the unborn child.

Nicotine produces pleasant feelings making you want either more cigarettes or more chew. As the body adapts to nicotine, smokers increase the number of cigarettes they consume, which leads to an increased level of nicotine in their blood. Nicotine is eliminated from the body inapproximately 3 days after stopping. Nicotine byproducts, such as cotinine, may remain in the body up to 10 days or longer in cases of heavy tobacco use.

Nicotine Withdrawal

The addiction to tobacco is as strong for some people as the addiction to heroin, alcohol, and cocaine. Tobacco users suffer from both physical and psychological withdrawal when they quit smoking or chewing. Both must be addressed in order for the quitting process to be successful.

Withdrawal symptoms can include any of the following

  • dizziness
  • depression
  • feelings of anger and frustration
  • irritability
  • sleep disturbances
  • trouble concentrating
  • restlessness
  • headache
  • increased appetite

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Many times people who are trying to quit will start smoking again in order to alleviate these unpleasant withdrawal symptoms. These physical symptoms subside over a period of time. However, for some, the symptoms are so strong they feel their only choice is to smoke or chew. And, when coupled with the psychological addiction, the person may feel unable to function in everyday life.

Keep in mind that these symptoms are short term, and will pass with time. Symptoms usually start within a few hours of the last use of tobacco and peak about 2 to 3 days later. They can last for a few days to several weeks.

Why Quit

Most people who are trying to quit smoking are doing so to improve their health. In addition to causing premature wrinkling of the skin, bad breath, and bad smelling clothes and hair, smoking is a major risk factor for the following cancers:

  • mouth
  • voice box (larynx)
  • throat (pharynx)
  • esophagus
  • trachea, bronchus
  • lung
  • acute myeloid leukemia
  • stomach
  • liver
  • pancreas
  • kidney and ureter
  • cervix
  • bladder
  • colorectal

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Smoking increases the risk of pneumonia, emphysema, chronic bronchitis, and peripheral vascular disease. Smokers are twice as likely to die from heart attacks as are nonsmokers. Life expectancy for smokers is at least 10 years shorter than for nonsmokers.

There is, however, good news. It is never too late to quit, and quitting now will help you live longer. You can also expect less sickness and better health. Quitting smoking before the age of 40 reduces the risk of dying from smoking-related disease by about 90%.

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Benefits of Quitting

Your can expect the following benefits once you put down your final cigarette:

  • 20 minutes after quitting: Your heart rate and blood pressure drops.
  • 12 hours after quitting: The carbon monoxide level in your blood drops to normal.
  • 2 weeks to 3 months after quitting: Your circulation improves and your lung function increases.
  • 1 to 9 months after quitting: Coughing and shortness of breath decrease; cilia (tiny hair-like structures that move mucous out of the lungs) regain normal function in the lungs, increasing the ability to handle mucus, clean the lungs, and reduce the risk of infection.
  • 1 year after quitting: The risk of coronary heart disease is half that of a smoker’s.
  • 5 years after quitting: Your stroke risk is reduced to that of a nonsmoker 5 to 15 years after quitting.
  • 10 years after quitting: The lung cancer death rate is about half that of a continuing smoker’s. The risk of cancer of the mouth, throat, esophagus, bladder, cervix and pancreas decrease.
  • 15 years after quitting: The risk of coronary heart disease is that of a nonsmoker’s.

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After quitting you can expect your sense of smell to return to normal, your food to taste better, and ordinary activities will no longer leave you out of breath. (Keep in mind that the benefits of quitting smoking far outweigh any risks from the 5-10 pounds you may gain.) You can also expect to save a significant amount of money. Multiply how much you spend on tobacco each day by 365. Think of all you could do with this extra money if you did not smoke. Don’t forget to factor in additional expenses such as higher costs for health and life insurance and the health care costs due to tobacco-related conditions.

Ready to Quit?

Studies have shown that most smokers benefit from participating in a tobacco cessation program and/or the use of nicotine replacement therapy. In fact, only about five in one hundred people are successful in quitting “cold turkey.” The ultimate or ideal treatment intervention has been researched for decades. Unfortunately this perfect treatment has yet to be found. What researchers do know is the pairing of nicotine replacement therapy and/or certain medications with a program that helps to change behaviorcandouble the success rates for abstinence from tobacco. Studies have shown that there is a strong relationship between the number and length of counseling sessions and successful treatment outcomes. Meeting with a counselor for four or more sessions is especially effective in increasing success.

Source: Fiore, Michael et al., Treating Tobacco Use and Dependence. 2008.

All patients attempting to quit should be encouraged to use effective pharmacotherapies except in the presence of special circumstances. The Food and Drug Administration has approved 7 first line medicines to be used in the treatment of tobacco addiction.

  1. bupropion SR (Zyban® or Wellbutrin®)
  2. varenicline (Chantix™)
  3. nicotine patch
  4. nicotine gum
  5. nicotine inhaler
  6. nicotine nasal spray
  7. nicotine lozenge

Many former smokers say a support network of family and friends was very important during their quit attempt. Other people who may offer support and encouragement are coworkers, your family doctor, your health coach, and members of support groups for quitters.

It’s Your Life participants may take advantage of Allegiance Health’s Tobacco Treatment program by calling841-7444. The Michigan Department of Community Health also has a tobacco quit line that can be accessed by calling 1(800)QUIT-NOW. Both of these programs are free of charge.

As of January 1, 2014 tobacco cessation must be provided at no cost under most types of health insurance. Contact your health plan provider to determine what is covered.

Source: Fiore, Michael et al., Treating Tobacco Use and Dependence. 2008.

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Nicotine Replacement Therapy

It is the nicotine in the cigarettes that leads to the physical addiction. Nicotine replacement therapy provides nicotine without all of the harmful chemicals that are found in tobacco. This helps reduce the physical symptoms and allows the smoker to focus more on the psychological aspects of quitting.

When the physical withdrawal symptoms are alleviated, the individual is more comfortable and therefore more likely to continue to abstain. The period of abstinence, coupled with behavioral counseling and pharmacotherapy, may give the person renewed confidence and determination to obtain permanent abstinence. The psychological addiction may persist much longer than the physical addiction and requires behavior modification. Behavior change is a process that occurs with practice and over time.

Types of Quit Medications/Products

Bupropion (Zyban/Wellbutrin)

Bupropion is a prescription antidepressant that reduces the symptoms of nicotine withdrawal. It does not contain nicotine but affects chemicals in the brain that control the nicotine craving. In studies it has been shown to almost double long-term abstinence rates when compared to a placebo. It can be used alone or with other nicotine replacement. The usual dosage is one or two 150 mg tablets per day.

It should not be taken by those with a history of seizures, head trauma, anorexia, bulimia, or heavy alcohol use. There is a warning on the label cautioning patients about the risk of mental health events including changes in behavior, depressed mood, hostility, and suicidal thoughts when taking the drug.

Source: Fiore, Michael et al., Treating Tobacco Use and Dependence. 2008.

Varenicline (Chantix)

Varenicline is a new medicine that lessens the pleasurable physical effects from smoking and reduces the unpleasant symptoms of nicotine withdrawal. It accomplishes this by interfering with nicotine receptors in the brain. It was developed specifically to help people quit smoking.

Recent studies have found that varenicline can more than double the chances of quitting smoking. Although generally well-tolerated, side effects may include headaches, nausea, trouble sleeping, and unusual dreams. There is also a warning on the label cautioning patients about the risk of mental health events including changes in behavior, depressed mood, hostility, and suicidal thoughts when taking the drug. It is not recommended to combine the use of varenicline with any other quit medications or products at this time.

Nicotine Patch

Patches can be purchased over the counter or with a prescription. They have been shown to almost double long-term abstinence rates. They provide a measured dose of nicotine through the skin. The dose is gradually lowered over the course of weeks and the smoker is weaned off of nicotine. Package inserts describe how to use the patches, as well as possible side effects.

Source: Fiore, Michael et al., Treating Tobacco Use and Dependence. 2008.

Possible side effects include:

  • skin irritation – redness and itching
  • dizziness
  • racing heartbeat
  • difficulty sleeping or unusual dreams
  • headache
  • nausea
  • vomiting
  • muscle aches and stiffness

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To help alleviate these side effects, try switching to a different brand of patch or reducing the amount of nicotine by lowering the dose. Sleep problems may improve after 3 to 4 days. If the symptoms do not improve, you may want to consider an alternative form of nicotine replacement.

Nicotine Gum

Nicotine gum is purchased over the counter and comes in 2 mg and 4 mg strengths. It is fast-acting and works through the mucous membrane of the mouth. It has been shown to improve long-term abstinence rates by approximately 30-80 percent.

Source: Fiore, Michael et al., Treating Tobacco Use and Dependence. 2008.

Follow the instructions included with the gum. Nicotine gum is not continuously chewed like bubble gum. Slowly chew the gum until you get a peppery taste and then “park” it between your teeth and gums. Repeat this process off and on for 20 to 30 minutes. Food and drink can affect how well the nicotine is absorbed and should be avoided for at least 15 minutes before and during gum use.

Heavy smokers may need to start with the 4mg dose and no more than 20 pieces should be used in one day. Nicotine gum is usually recommended for 1 to 3 months, with the maximum number being 6 months. Gradually decreasing the amount of gum chewed may help you stop using it.

Nicotine gum is a good choice for those with sensitive skin or individuals that want to control the nicotine doses. It can be chewed on a fixed schedule (1-2 pieces per hour), or as-needed. Possible side effects include:

  • bad taste
  • throat irritation
  • mouth sores
  • hiccups
  • nausea
  • jaw discomfort
  • racing heartbeat

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One possible disadvantage of nicotine gum is long-term dependence. Although the maximum recommended length of use is 6 months, 15% to 20% of those that are successful quitting continue using the gum for a year or longer. While there is little research on the health effects of long-term nicotine gum use, it is likely safer than going back to smoking. Discuss it with your physician if you plan on using nicotine gum longer than 6 months.

Nicotine Inhaler

Nicotine inhalers are available by prescription only. It has been shown to more than double long-term abstinence rates. A plastic tube with a nicotine cartridge on the inside, it provides a nicotine vapor when you puff on the inhaler. They are the closest thing to smoking a cigarette, which some smokers find helpful. On the down side, they are currently the most expensive form of nicotine replacement therapy. The recommended dose is 6 to 16 cartridges per day, for up to 6 months. It is important to note that you must not inhale but rather puff to release nicotine into the mouth.

Possible side effects include:

  • coughing
  • throat irritation
  • upset stomach

Source: Fiore, Michael et al., Treating Tobacco Use and Dependence. 2008.

Nicotine Nasal Spray

Nicotine nasal spray is available only by prescription and delivers nicotine quickly to the bloodstream. It is applied to the inside of the nostril without sniffing and absorbed through the lining of the nose making it very easy to use. It has been shown to more than double long-term abstinence rates.

Source: Fiore, Michael et al., Treating Tobacco Use and Dependence. 2008.

Since it is absorbed through the nose and enters the bloodstream quickly, it immediately relieves withdrawal symptoms and offers a sense of control over nicotine cravings. Because it contains nicotine, it can be addictive. There is also the danger of using more than is needed. The FDA recommends the spray be prescribed for 3-month periods and it should not be used for longer than 6 months.

Side effects last on average 1 to 2 weeks and include:

  • nasal irritation
  • runny nose
  • watery eyes
  • sneezing
  • throat irritation
  • coughing

If you have asthma, allergies, nasal polyps, or sinus problems, your doctor may suggest another form of nicotine replacement.

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Nicotine Lozenges

The nicotine lozenge isanother short acting nicotine replacement therapy and can be purchased over-the-counter. It is available in two strengths: 2 mg and 4 mg.

The instructions recommend using it as part of a 12-week program. The recommended dose is one lozenge every 1-2 hours for 6 weeks, then one lozenge every 2-4 hours for weeks 7 to 9, and finally, one lozenge every 4-8 hours for weeks 10 to 12. The following is also recommended:

  • Stop all tobacco use when beginning therapy with the lozenge.
  • Do not eat or drink for 15 minutes before using the lozenge.
  • Do not bite or chew the lozenge. Place it between your cheek and gum and allow it to dissolve. Alternate from side to side.
  • Do not exceed 5 lozenges in 6 hours or more than 20 per day.
  • Stop using after 12 weeks. Talk to your doctor if you still feel the need to use the lozenges.
  • Do not use the lozenge if you continue to smoke or use any tobacco product.
  • The lozenge is not recommended for those with asthma.

Possible side effects of the nicotine lozenges include:

  • trouble sleeping
  • nausea
  • hiccups
  • coughing
  • heartburn
  • headache
  • flatulence (gas)

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Choosing the Right Nicotine Replacement Therapy

There is no evidence that any type of nicotine replacement therapy is significantly better than another. What works for one of your friends or your spouse, may not work for you. The key is to keep trying until you are successful. Try to think about which method would best fit your lifestyle.

Some points to consider:

  • Nicotine patches are convenient and only have to be applied once per day.
  • Nicotine gums, lozenges, and inhalers are oral substitutes that allow you to control your dosage to help keep cravings under better control.
  • Nicotine inhalers allow you to mimic the use of cigarettes by puffing and holding the inhaler.
  • Both inhalers and nasal sprays require a doctor’s prescription.
  • Nicotine nasal spray works very quickly when you need it.
  • Some people may not be able to use patches, inhalers, or nasal sprays due to allergies or other conditions.

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