Appropriate use of pharmacotherapy, such as nicotine replacement therapy (NRT), bupropion or varenicline, can double a person's chances of successfully quitting tobacco.
There are different medications and therapies that may help during the quitting process. Learn more.
Nicotine Replacement Therapies (NRTs)
- With smoking, nicotine is delivered via the lungs to the brain in 7-10 seconds, offering almost instantaneous effects.
- Among NRTs, nasal spray has the most rapid absorption, followed by the gum, lozenge, and inhaler; absorption is slowest with the transdermal formulations.
- Because NRTs deliver nicotine more slowly and at lower levels (e.g., 30-75% of those achieved by smoking), these agents are far less likely to be associated with dependence.
- Aim of NRT is to replace nicotine from cigarettes without other harmful components of tobacco smoke.
- Using nicotine replacement therapies double one's likelihood of successfully quitting smoking by reducing withdrawal symptoms.
- Careful consideration should be used when recommending NRT for persons with active or uncontrolled heart disease:
- Patients with recent MI (within 2 weeks)
- Patients with underlying arrhythmias or worsening angina
- Although NRT is not absolutely contraindicated for pregnant and lactating women, it should only be prescribed when it is determined that the benefits of taking NRT outweigh the risks.
- NRT has not been approved by the FDA for use in youth.
Nicotine Chewing Gum (Nicorette)
- Nicotine is released from the gum and absorbed through the gum tissue to reduce cravings.
- Most common adverse effects: gastrointestinal disturbances, dyspepsia, nausea and hiccups, occasional headache if the gum is chewed too quickly, jaw pain, and dental problems.
- Tips for Use
- Chew gum slowly until peppery or tingling sensation appears (~15 to 30 chews).
- Park gum between cheek and gum.
- Resume chewing when sensation fades.
- Repeat chew/park steps until sensation does not reappear.
- Park gum at different parts of the mouth.
- No food or drink 15 minutes before or during use.
| Patients who smoke their first cigarette >30 minutes after waking | 2 mg | One piece can be chewed every 1-2 hours or as needed Maximum 24 pieces per day Minimum duration 12 weeks |
| Patients who smoke their first cigarette <30 minutes after waking | 4 mg | One piece can be chewed every 1-2 hours or as needed Maximum 24 pieces per day Minimum duration 12 weeks |
Nicotine Lozenge (Nicorette)
- Most effective when dissolved in the mouth; avoid chewing or swallowing.
- Most common adverse effects: gastric and throat irritation.
- Tips for Use
- Allow to dissolve in mouth slowly (20-30 minutes); nicotine release may cause a tingling sensation.
- Rotate to different areas of mouth.
- No food or drink 15 minutes before or during use
| Patients who smoke their first cigarette >30 minutes after waking | 2 mg | One lozenge can be used every 1–2 hours or as needed Maximum 20 per day Minimum duration 12 weeks |
| Patients who smoke their first cigarette within 30 minutes of waking | 4 mg | One lozenge can be used every 1–2 hours or as needed. Maximum 20 per day Minimum duration 12 weeks |
Nicotine Patch (NicoDerm CQ)
- The patch provides a low continuous dose of nicotine that is absorbed through the skin.
- The patch is applied once a day and worn for 16-24 hours.
- Duration of therapy for at least 8 to 12 weeks.
- Tips for use:
- Apply one new patch every 24 hours on skin that is dry, clean and hairless.
- Wash hands after applying or removing patch.
- Do not cut patch and do not wear more than once patch at a time.
- The most common adverse reaction is skin irritation.
- If sleep disturbance occurs, apply for 16 hours and remove at night.
| >10 cigarettes/day | 21 mg/24 hour patch | At least 8 to 12 weeks Tapering not required |
| <10 cigarettes/day | 14 mg/24 hour patch | At least 8 to 12 weeks Tapering not required |
Nicotine Inhaler (Nicotrol Inhaler) Prescription only and require PA for Medicaid coverage
- Nicotine is absorbed through the throat and mouth when inhaling.
- Recommended dose for monotherapy: 6-16 cartridges per day for the first 6-12 weeks.
- Start tapering over the next 6-12 weeks.
- Initial dosing of the nicotine inhaler is individualized "as needed" and tapered over the course of therapy.
- Often used as needed in combination with nicotine patches.
Nicotine nasal spray (Nicotrol NS) Prescription only and require PA for Medicaid coverage
- Can be used up to five times an hour, and no more than 40 times in a day.
- Usual dose is two sprays, one in each nostril.
- For monotherapy start at 1-2 doses/hour; maximum dose is 5 doses/hour or 40 doses/day.
- Treatment for up to 8 weeks then stopping or tapering dose for 4-6 weeks.
- Can also be used as needed in combination with nicotine patches.
- The spray has not been widely used because many find it irritating and uncomfortable.
Non-Nicotine Oral Therapy
Bupropion SR (Wellbutrin, Zyban)
- Exact mechanism is unknown; it is thought to work by enhancing dopamine levels.
- Helps to reduce withdrawal symptoms.
- Should be started one to two weeks before one's quit date.
- Recommended dose: 150 mg once per day for 3 days, increasing to 150 mg twice per day for 12 weeks.
- Can be combined with NRT to help improve success rates
- Main adverse effects: insomnia, headache, dry mouth, nausea, dizziness, and anxiety
- Serious adverse events: rare incidences of seizures
- Bupropion is contraindicated in the following patients:
- Allergy to bupropion
- Current use of bupropion (Wellbutrin) therapy
- Past or current seizures
- Known central nervous system tumors
- Patients undergoing abrupt withdrawal from alcohol or benzodiazepines
- Current or previous history of bulimia or anorexia nervosa
- Use of monoamine oxidase inhibitors within the past 14 days
- Monitor for neuropsychiatric symptoms (changes in behavior, agitation, depressed mood, and suicidal ideation).
- Use caution with renal and liver failure.
Varenicline (Chantix)
- Chantix prevents nicotine from stimulating the brain and reduces the pleasure received when smoking, helping to reduce cravings and withdrawal symptoms.
- Smokers are often instructed to start varenicline one week before quit date, but a longer preloading period (e.g. 1 month) is also effective in helping smokers stop cigarettes.
- The dose is gradually up titrated to minimize side-effects:
- Take one white tablet daily (0.5mg) for 3 days
- Then one white tablet (0.5 mg) twice daily for 4 days
- Then one blue tablet (1mg) twice daily for up to 12 weeks
- Can be combined with NRT to help improve success rates.
- Monitor for neuropsychiatric symptoms (changes in behavior, agitation, depressed mood, and suicidal ideation).
- Other adverse effects include nausea (can be minimized by taking with food and a full glass of water, abnormal/vivid dreams, and insomnia.
- Dose reduction is required in patients with kidney disease and on hemodialysis.