Quitting doesn’t look the same for everyone, which is why there are so many different strategies and remedies to assist people with reducing, and eventually quitting smoking all together. I want to present the whole “menu of options” of pharmacotherapy to you, so that you are best equipped to make an informed decision that is right for you and your goals with your tobacco use.
First, let’s do a general walk through of pharmacotherapy and how it can be helpful
What is pharmacotherapy?
Pharmacotherapy is the use of FDA regulated medication to assist an individual with medical conditions, such as addiction. Regarding nicotine dependency specifically, there are two types of pharmacotherapy: nicotine replacement therapy (NRT) and medication in the form of a pill.
Evidence-based studies have proven that people who use tobacco products are two times more likely to be successful in their quit attempt if they combine nicotine dependency counseling with some form of pharmacotherapy, compared to using either pharmacotherapy or counseling alone.
There are many factors at play that make quitting so hard (societal, cognitive, the length of time someone has been smoking, etc.) but today we are going to focus on nicotine withdrawals and utilizing pharmacotherapy as a means to reduce the negative effects caused by withdrawals. Nicotine withdrawals can be a lot more difficult than most people think, and are a huge barrier to quitting tobacco use due to the extreme discomfort they can cause. For this reason, it is crucial that you know your options as someone who is trying to quit using tobacco products.
What are nicotine withdrawal symptoms and why do they occur?
Nicotine withdrawals occur as symptoms of your brain adjusting to the new “normal” as nicotine levels fall within your brain, and eventually leave your system. Nicotine can leave your body entirely within a few days, thanks to the short half-life of the drug. It is important to note that just because the nicotine leaves your system so quickly does not mean that withdrawals will leave as quickly. Most people who quit smoking experience extreme symptoms to nicotine withdrawal for 1-2 weeks with withdrawal usually reaching its peak by day 3, and it can take a few months for them to be gone entirely. This is because it takes up to 3 three months for your brain chemistry, specifically dopamine receptors, to return to “normal” pre-smoking levels.
A more thorough explanation of how withdrawal happens, and why it takes so darn long for things to feel “normal” or for life to feel good again after quitting
Before you smoked, your brain created its own pleasure response (flood of dopamine) to daily activities such as spending time with people you enjoy, eating, having sex, and plenty of other activities. When you start smoking, your brain “doubles down” on the pleasure response thanks to nicotine increasing the volume of the pleasure response that becomes available to you as you smoke (or chew).
Over repeated use, your brain drastically reduces the amount of pleasure response that is created on its own, without cue from nicotine, since the nicotine makes it so readily available anyways. Think of it this way- if you have a child who regularly cleans their room every day, but you start cleaning their room while they’re at school, they will stop doing it themselves. This is what your brain is doing (or not doing) as nicotine triggers the release of dopamine When you stop using tobacco products, your brain doesn’t catch on right away, so you are receiving much less pleasure response (dopamine) than you were when you were using tobacco, but now you’re also receiving less pleasure response than before you started smoking in the first place. This results in life feeling less satisfactory in a variety of ways.
After increased abstinence, your brain plays catch up, and the dopamine levels in your brain return to the pre-smoking levels. Life is bearable, and even enjoyable again. Understanding this aspect of nicotine withdrawal can help make the experience much less daunting, and give hope that better days really are to come and that all pleasure is not lost once you kick the cigarettes out of your life.
Below is a list of common nicotine withdrawal symptoms:
- Cravings (can be general, also the sense of needing something in your mouth constantly)
- Irritability
- Trouble concentrating
- Anxiety
- Depression/crying spells
- Increased hunger/ weight gain
- Fatigue
- Headache
Now, time to see all of your options for keeping the above withdrawals at bay during your quit journey.
Your Guide to Pharmacotherapy for Reducing or Quitting Tobacco Use
***This information is purely educational, so that you understand what all of your options are and how each works. It is always wise to consult with a doctor or tobacco treatment specialist when utilizing any medication to help with reducing or quitting smoking in order to make sure that the dosing and recommendations are safe and make sense for your unique smoking pattern and nicotine dependency.***
Nicotine Replacement Therapy (NRT)
There are many options for someone who wishes to utilize nicotine replacement therapy, and nicotine replacement therapy seems to be the most popular form of assistance from my clientele base. There are five different types approved by the FDA, outlined below.
The Patch
How you use it: The nicotine patch is a transdermal patch that you put on each day (most people find it easiest to remember by replacing it each morning) and keep on throughout the day. It gives you a steady stream of nicotine throughout the day, in order to help stave off withdrawal symptoms while reducing or quitting.
How it works: The nicotine patch is the only NRT that is slow acting. What that means, is that the patch slowly releases an equal amount of nicotine into your bloodstream for the full day that you wear it. This is important, because the slow and steady release of nicotine into your system helps your body fight the nicotine addiction by making its presence less enforcing as you are no longer self-medicating as a direct response to triggers that may have effected your smoking patterns in the past. It is encouraged to pair a slow acting and quick acting NRT together to maximize success in quitting.
Dosing: Depends on recommendations made by your Tobacco Treatment Specialist (TTS) or Physician, but most people who smoke 1 pack per day or more utilize the 21mg patch to start. It also comes in 14mg and 7mg quantities.
Cautions: Using the patch can be very helpful as a means to help individuals reduce their tobacco use but please utilize caution and consult with your doctor or TTS if you are using the patch while still smoking. Nicotine poisoning can cause rapid heartbeat, nausea, and in severe cases, result in a heart attack.
Nicotine Gum
How you use it: You chew the gum until it begins to taste “peppery” or not enjoyable. This change in taste as you chew it is the nicotine being activated to be released. Once the taste changes, you “park” the gum between your lip and your gums and keep it there for 15-30 minutes as the nicotine being released will then be absorbed by the mucous membranes that line your cheek.
How it works: The nicotine gum delivers nicotine to your system within a few minutes. It is a fast-acting NRT, meaning that it kicks in relatively quick. The dosing is quite small, making it a great companion to the patch when you quit. I usually recommend that clients utilize the gum in addition to the patch, as something to supplement getting through mornings or rough triggers, as they are waiting for the patch to kick in. Even with the gum delivering nicotine to your bloodstream within a few minutes, it is helping your body kick the withdrawals while also continuing to eliminate the positive reinforcement of smoking/utilizing nicotine as a stress response. This is because the delivery of nicotine to your bloodstream within a few minutes is still relatively slow when compared to the 7 seconds that it takes for nicotine to be delivered to your bloodstream when you are smoking a cigarette.
Dosing: The nicotine gum comes in 4mg and 2mg doses.
Cautions: Please make sure that you do not continue chewing the gum past the peppery taste and NEVER swallow the gum. Spit it out into the trash when you are done. With the dosing being so small with the gum, the chances of getting nicotine poisoning are extremely low, but you’re in for a nasty stomach ache and/or nausea if you swallow the nicotine gum directly.
Nicotine Lozenge
How you use it: Move the lozenge from one side to the other side of your mouth often, allowing it to slowly dissolve for about 20-30 minutes. Avoid chewing the lozenge.
How it works: The nicotine lozenge acts very similar to the Nicotine Gum and delivers nicotine to your system within a few minutes. It is a fast-acting NRT, meaning that it kicks in relatively quick. The dosing is quite small, making it a great companion to the patch when you quit. I usually recommend that clients utilize the lozenge in addition to the patch, as something to supplement getting through mornings or rough triggers, as they are waiting for the patch to kick in. Even with the lozenge delivering nicotine to your bloodstream within a few minutes, it is helping your body kick the withdrawals while also continuing to eliminate the positive reinforcement of smoking/utilizing nicotine as a stress response. This is because the delivery of nicotine to your bloodstream within a few minutes is still relatively slow when compared to the 7 seconds that it takes for nicotine to be delivered to your bloodstream when you are smoking a cigarette.
Dosing: The nicotine lozenge comes in 4mg and 2mg doses. It also comes in a variety of flavors (mint, cinnamon, fruit).
Cautions: Do not chew or swallow the lozenge, as this can cause a stomach ache and/or nausea. It is advised to not use more than 1 lozenge an hour- especially if you are already using it with the patch.
*This product is only available by prescription from a doctor
How you use it: You should not begin to use an inhaler until after you have stopped smoking (on your quit date). It is also advised to not eat or drink 15-30 minutes before using the inhaler, to avoid irritation of the mouth. Once you put a nicotine cartridge into the inhaler, you inhale similarly to using an asthma inhaler, slowly letting the nicotine vapor absorb into your mouth and throat area. 
How it works: The inhaler mimics the look of a cigarette and contains a cartridge that fits in the inhaler, containing nicotine. Since you are absorbing the nicotine through your mucous membranes (inside of mouth, throat), you do not receive the same “hit” in your lungs like if you were to smoke a regular cigarette. The nicotine inhaler does not deliver nicotine to your brain as quickly as smoking a cigarette which helps prevent the positive reinforcement of nicotine consumption, allowing you to slowly taper down your use and prevent the onset of extreme nicotine withdrawal. The inhaler is great for heavier smokers (1-2 packs a day), as it helps you slowly ease out of your routine of grabbing a cigarette and putting it to your mouth.
Dosing: One nicotine cartridge contains enough nicotine for 20 minutes of “puffing.” It is recommended to use each cartridge in four separate five minute sessions, and to stick to less than 16 cartridges a day unless otherwise advised by a doctor. Most people end up using between six to ten cartridges a day.
Cautions: Make sure you dispose of the nicotine cartridges safely when finished, as there could be lingering nicotine inside that could harm pets or small children that come in contact with it. Discontinue use after six months. The mouthpiece should be regularly cleaned and disinfected to prevent bacteria build up.
*This product is only available by a prescription from your doctor
How you use it: When you have quit smoking completely, you may start using this product (quit date and beyond). You use this product just like you would use a nasal spray for colds/nasal congestion. After washing your hands, you should blow your nose in order to clear your nasal passageways.
How it works: This nicotine replacement therapy enters the blood stream quicker than the other forms of NRT due to it being absorbed through the nasal passage way. This increases the chance of the nasal spray being more habit forming than the other methods.
Dosing: Most people start with one or two doses an hour, but this can vary based on how many cigarettes you smoked a day before your quit date. Never use more than five doses an hour, or 40 doses within a 24 hour day.
Cautions: Wait at least five minutes after use before driving or operating heavy machinery. Use the nasal spray regularly to help your body adjust to the following side effects that most people experience within the first week of us: hot, peppery feeling in the back of the throat or nose, sneezing, coughing, watery eyes or runny nose. If you are recovering from drugs that required a similar method of use, this product might not be right for you.
Quit Smoking Medications
There are currently two types of medications that have been approved by the FDA to assist individuals with quitting smoking. They are proven to be as effective as NRT.
*Both of these medications require a prescription by a doctor
How you use it: You can start taking Chantix before you quit smoking, as it takes some time for the medication to build up in your system. Some people take Chantix a week before their quit date, and others try an even more gradual quit approach and take Chantix for 12 weeks as they are working towards quitting and then remain on Chantix for an additional 12 weeks after quitting. When you do start taking Chantix, there is a specific protocol that you will take so that you can slowly increase the dose over the first week. It is advised to take the pill after eating a meal with a full glass of water.
How it works: When you start taking Chantix, as it builds up in your system, it attaches to the nicotine receptors in your brain. This makes smoking less enjoyable as the nicotine receptors are blocked in your brain and the nicotine is unable to release the flood of dopamine that usually occurs when you smoke. In turn, this helps break the reward cycle of smoking, which ends up lessening your urges to smoke. And if you do smoke while taking Chantix, the effect is significantly less pleasurable. Additionally, since Chantix is now binding to the nicotine receptors in your brain, it does produce a small amount of dopamine to mimic the effect of smoking… only on such a small level that it is not addictive, and just to serve the purpose of easing nicotine withdrawal symptoms.
Dosing: The dosing schedule can vary based on specific needs, but generally follows the following protocol: Days 1-3 you take 1 white pill (.5mg) daily, on Days 4-7 you take 1 white pill (.5mg) in the morning and 1 in the evening. Finally, on day 8 until the end of your treatment regimen you take 1 blue pill (1mg) in the morning and 1 in the evening. This allows the medication to slowly build up in your system in a safe way.
Cautions: If you have a history depression or other mental health conditions, or a history of seizures, this may not be the best option for you. A variety of side effects can occur with this medication and it is important to discuss these with your doctor if you are thinking about using this method to quit smoking.
Zyban / Wellbutrin (Bupropion)
How you use it: Most people will start taking Bupropion 1-2 weeks before their quit date, or as they are reducing, to allow the medication to build up in your system before you officially quit.
How it works: It is still unclear precisely how Bupropion works, though it has been proven to be effective in easing irritability, concentration problems, and the urge to overeat while quitting smoking. Researchers do know that Bupropion blocks some of the chemicals in your brain that interact with nicotine, making smoking and other tobacco use less re-enforcing, leading to reduced cravings. Bupropion is also commonly prescribed as an anti-depressant.
Dosing: Days 1-3 you take one 150mg tablet each morning, day 4 to the end of your treatment regimen you take one 150mg tablet twice a day- once in the morning and once in the evening (about 8 hours between doses).
Cautions: If you have a history of anxiety, anorexia, binge drinking, or seizures, this medication might not be for you. It is important to discuss your medical history with your doctor if you are interested in taking this medication for smoking cessation.
Additional Notes
If you are pregnant, breastfeeding, or are under the age of 18 you should consult with a doctor before using any of the above medications or NRT.
Get a prescription anyways and save your money to use on other things that will assist your reduction or quit, such as gum, sugar-free candy, toothpicks, etc.
Although you can get the patch, gum and lozenge over the counter at most stores, they can get quite expensive. Especially if you plan to use them for 6 months (the maximum amount of time suggested to help prevent relapse after quitting). With a prescription from your doctor, you can receive these products for free or a substantially reduced price, as many insurance companies will cover the cost to help individuals quit smoking with evidence based interventions. Why pay for it if you don’t have to? In the light of COVID-19, it might not be possible to go into your doctor’s office physically. Instead, you can schedule a virtual “telehealth” visit or try calling the office to explain your situation.
If you are uninsured or underinsured, call the Michigan Quitline at 1-800-QUIT-NOW (1-800-784-8669) to see how you can get NRT mailed directly to your door.
Feel like you need to adjust your tobacco treatment plan due to COVID-19 or just interested in finding out more about Unified’s Tobacco Reduction services? Contact your local Tobacco Treatment Specialist:
Detroit:
Amber Jager – (269) 350-3826
ajager@miunified.org
Ypsilanti/Jackson:
Caitlyn Clock – (734) 489-9916
cclock@miunified.org
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