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How does nicotine replacement therapy work?

Nicotine replacement therapy (NRT) can help with the withdrawal symptoms and cravings that most people say is their only reason for not quitting tobacco. Using NRT reduces these symptoms.

Many people can quit tobacco without nicotine replacement therapy. But most people who attempt quitting don’t succeed on the first try. In fact, people trying to quit usually need many attempts before they’re able to quit for good.

Most people who try to quit on their own go back to smoking within the first month of quitting. This is often because of the withdrawal symptoms. But the good news is that many people do succeed. In fact, there are now more people who formerly smoked than people who currently smoke.

Together with counseling or other support, NRT may also help increase the number of smokeless tobacco users who quit.

The Food and Drug Administration (FDA) has approved the NRT products discussed here as effective aids for helping people quit smoking. None of these products has been FDA-approved specifically to help people quit smokeless tobacco. But some studies have shown the lozenge form of NRT might help.

When can I start using it?

You can start using nicotine replacement therapy as soon as you throw away your tobacco. You don’t need to wait before you put on the patch or start using the gum, lozenge, nasal spray, or inhaler.

Double-check this information with the instructions on your chosen method of nicotine replacement. But in general, there’s no need to wait to start using NRT.

Getting the most from nicotine replacement therapy

Nicotine replacement therapy (NRT) only helps with physical dependence. It’s not meant to be the only thing you use to help you quit tobacco. You’ll need other ways to manage the emotional and mental part of stopping tobacco, such as a quit program.

Use a quit program or other support system during treatment with NRT and for at least a few months after you quit.

Studies show that pairing NRT with a program that helps change behavior can improve your chances of quitting and staying quit (compared to using only one method).

The best time to start NRT is when you first quit.

Some people first try to quit tobacco on their own then decide to try NRT a day or more into quitting. This doesn’t give you the greatest chance of success. But if you already did this, don’t let it discourage you. There are many options for quitting and staying quit.

Nicotine patches (transdermal nicotine systems)

Nicotine patches can be bought by people over 18 years of age with or without a prescription.

Patches give a measured dose of nicotine through your skin. Nicotine is slowly released over a 24-hour period, so you get a steady dose. You’re weaned off nicotine by switching to lower-dose patches over a period of weeks.

Many different types and strengths of patches are available including 7, 14, and 21 milligram patches. Which dose you should use depends on how many cigarettes you smoke each day. Package instructions tell you how to use them. They also list safety concerns and possible side effects.

How to use nicotine patches

Depending on smoking habits, most people who smoke should start using a full-strength patch (21 mg of nicotine) daily for several weeks and then use a weaker patch (14 mg of nicotine) for another several weeks.

The patch is changed every day. It should be put on in the morning on a clean, dry area of your skin without much hair. It should be placed below your neck and above your waist (for example, on your upper arm or chest).

The FDA has approved using the patch for a total of 3 to 5 months, but using it longer is better than going back to smoking. Talk to your health care team if you think you need to use the patch for longer.

Possible side effects

• Skin irritation (redness, itching or burning)
• Headache
• Sleep problems or unusual dreams

No one has all the side effects, and some people have none. Stop using the patch and talk to your health care provider if you have any of these symptoms. You could also have nicotine withdrawal symptoms if your NRT dose is too low.

What to do about side effects

• Try a different brand of patch if your skin becomes irritated.
• Reduce the amount of nicotine by using a lower-dose patch.
• Sleep problems may go away in 3 or 4 days. If not, try removing your patch before you go to bed.
• Stop using the patch and try a different form of NRT.

Nicotine gum (nicotine polacrilex)

Nicotine gum can be bought over the counter (without a prescription).

Nicotine gum is a fast-acting form of NRT. Nicotine is taken in through the lining of the mouth. It comes in 2 mg and 4 mg strengths.

The dose of nicotine gum you use will depend on when you normally smoke your first cigarette after waking up. If you normally smoke your first cigarette within 30 minutes of waking up, use 4 mg nicotine gum. If you normally smoke your first cigarette more than 30 minutes after waking up, use 2 mg-nicotine gum.

How to use nicotine gum

Before you start using nicotine gum, be sure to read any instructions that come with the package. Nicotine gum is not meant to be used like regular gum. To get the best effect:

• Chew the gum slowly until you feel a tingling in your mouth.
• Then tuck it inside your cheek until the taste fades.
• Chew the gum again to get the tingling feeling back and tuck it inside your cheek again.
• Do this off and on for 20 to 30 minutes until the tingling feeling stops.
• Don’t eat or drink for at least 15 minutes before and during gum use. (Some drinks can reduce how well the gum works.)

These steps are important because if you chew it like regular gum, it may not have the desired effect.

How often to use it

To start, it’s suggested that you use nicotine gum every 1-2 hours on a regular schedule. To ease withdrawal symptoms, try to use at least 9 pieces of gum each day for the first 6 weeks. You can use it more often if you have cravings in between.

Chew no more than 24 pieces of gum in one day.

Nicotine gum is usually recommended for 6 to 12 weeks, with the maximum being 6 months. Tapering down the amount of gum you use as you approach 3 months may help you stop using it. But it is better to keep using the gum rather than starting to smoke again.

Possible side effects

• Bad taste
• Mouth or jaw soreness or irritation
• Upset stomach, hiccups, or too much saliva
• Nausea or vomiting
• Feeling lightheaded

Stomach and jaw discomfort are usually caused by improper use of the gum, such as swallowing the nicotine or chewing too fast. The gum can also stick to and damage dentures and dental work.

No one has all the side effects, and some people have none. If your heart is racing or beating irregularly, stop using the gum and talk to your health care provider. You could also have nicotine withdrawal symptoms if your NRT dose is too low.

Nicotine lozenges

Nicotine lozenges can be bought over the counter (without a prescription).

The lozenge is available in 2 strengths: 2 mg and 4 mg. The dose of nicotine lozenge you use will depend on when you normally smoke your first cigarette after waking up.

If you smoke your first cigarette within 30 minutes of waking up, use 4 mg nicotine lozenges. If you smoke your first cigarette more than 30 minutes after waking up, use 2 mg-nicotine lozenges.

Some people who use NRT prefer lozenges to the gum because they are less conspicuous.

How to use nicotine lozenges

The recommended dose for nicotine lozenges is:

• The first 6 weeks:1 lozenge every 1 to 2 hours
• Weeks 7 to 9: 1 lozenge every 2 to 4 hours
• Weeks 10 to 12: 1 lozenge every 4 to 8 hours

To ease withdrawal symptoms, try to use at least 9 lozenges each day for the first 6 weeks. You can use it more often if you have cravings in between.

The lozenge makers also recommend:

• Do not eat or drink for at least 15 minutes before using a lozenge or while using a lozenge. (Some drinks can reduce how well the lozenge works.)
• Do not use more than 1 lozenge at a time and do not use one right after another.
• Suck on the lozenge until it is fully dissolved, about 20 to 30 minutes. Move it from side to side in your mouth.
• Do not bite or chew it like a hard candy, and don’t swallow it. The nicotine absorbs through the mucous membranes of your mouth.
• Do not use more than 5 lozenges in 6 hours, or more than 20 lozenges per day.
• Stop using lozenges after 12 weeks. If you still feel you need to use them, talk to your doctor.

Possible side effects

• Nausea
• Hiccups
• Heartburn
• Trouble sleeping
• Headache
• Cough

If you have trouble sleeping when using nicotine lozenges, try not to use them for several hours before you go to sleep.

Nicotine nasal spray

Nicotine nasal spray is only available by prescription.

Nicotine in the nasal spray is absorbed through your nose. It relieves withdrawal symptoms quickly and helps you control your nicotine cravings.

How to use nicotine nasal spray

Most people are told to use 1 to 2 doses per hour. (1 dose = 2 sprays, 1 in each nostril.) You may need to take at least 8 doses (16 sprays) each day when you first start. Instructions can vary. Talk to your provider about the plan that’s best for you.

Don’t use more than 40 doses (80 sprays) per day. Using more than that can cause more serious side effects. The FDA recommends nicotine spray not be used for longer than 6 months.

Possible side effects

Common side effects of nicotine spray get better in 1 to 2 weeks. These side effects can include:

• Nose and throat irritation (hot, peppery feeling)
• Runny nose
• Watery eyes
• Sneezing
• Coughing

No one has all the side effects, and some people have none.

Some side effects, like racing heart, may happen because you’ve gotten too much nicotine. If this happens, stop using the spray to see if the feelings get better and talk to your health care provider.. You may need to use it less often. You could also have nicotine withdrawal symptoms if your NRT dose is too low.

If you have asthma, allergies, nasal polyps, or sinus problems, your provider may suggest another form of NRT.

Nicotine inhalers

Nicotine inhalers are only available by prescription.

The nicotine inhaler is a thin plastic tube with a nicotine cartridge inside. This is different from other inhalers which carry most of the medicine to the lungs. Nicotine inhalers give most of the nicotine vapor to the mouth and throat, where it’s absorbed.

Nicotine inhalers are the FDA-approved nicotine replacement method that’s most like smoking a cigarette. Some people trying to quit find this helpful. They are not the same as electronic cigarettes, which are not approved by the FDA to help people quit smoking.

How to use the nicotine oral inhaler

Take short, shallow puffs on the inhaler. This pulls nicotine vapor into your mouth. You may use up the cartridge all at once over about 20 minutes, or puff on it for about 5 minutes at a time. The suggested dose is at least 6 but no more than 16 cartridges a day, slowly tapering off over 6 months.

Possible side effects

The most common side effects, especially when first using the inhaler, include:

• Coughing
• Mouth and/or throat irritation
• Runny nose
• Headache
• Hiccups or upset stomach

No one has all the side effects, and some people have none.

Some side effects, such as racing heart, may happen because you’ve gotten too much nicotine. If this happens, stop using the inhaler to see if the feelings get better and talk to your health care provider. You may need to use it less often.

You might also have nicotine withdrawal symptoms if your NRT dose is too low.

Choosing and using the right nicotine replacement therapy for you

When deciding on a type of nicotine replacement therapy, think about which method best fits your lifestyle and pattern of smoking or using smokeless tobacco. For example, do you want/need something in your mouth or something to keep your hands busy? Are you looking for once-a-day convenience? How strong are your cravings for nicotine?

Here are some things to think about as you decide:

• Nicotine gums, lozenges, and inhalers are put into your mouth and let you control your dosage to help your deal with cravings.
• Nicotine gums and lozenges are generally sugar-free. But if you’re diabetic and have any doubts, check the package or contact the manufacturer.
• Nicotine nasal spray works very quickly.
• Nicotine inhalers allow you to mimic the use of cigarettes by puffing and holding the inhaler. They also work very quickly.
• Nicotine patches are convenient and only have to be put on once a day. They provide a steady level of nicotine for 24 hours.
• Inhalers and nasal sprays require a doctor’s prescription.
• Some people may not be able to use patches, inhalers, or nasal sprays because of allergies or other conditions.
• Nicotine gum may stick to dentures or dental work, making it hard to chew before you place them between your cheek and gums.

Whatever type you use, take your NRT at the recommended dose. Taking too little won’t give you the relief from cravings that you need. If you take too much, you may have serious side effects.

NRT is not recommended for long-term use, but if it's needed to prevent relapse, continuing to use it is preferable to returning to smoking. If you stop taking NRT too soon, the cravings might make you return to smoking again.

If you smoke very heavily, very lightly, or are a smokeless tobacco user, talk with your health care provider about how to get the NRT dose that is most likely to help you.

What is light, average, and heavy smoking?

Many nicotine replacement therapy (NRT) product recommendations are based on how much you smoke. But there’s no formal method that defines how much smoking is light, average, or heavy smoking.

These are general guidelines:

• Light smoking: Fewer than 10 cigarettes per day
• Heavy smoking: A pack a day or more
• Average smoking falls in between.

How do I know what NRT dose to use to help me quit smokeless tobacco?

Your NRT dose should roughly match the amount of nicotine you take in each day. It can be more of a challenge to get the dose right for smokeless tobacco users, since NRT products are labeled for people who smoke.

Certain types of NRT may help more than others. For example, nicotine gum and lozenges are most like using smokeless tobacco. They also let you control your dose to help keep nicotine cravings down. To avoid withdrawal symptoms, you want to aim for a nicotine dose fairly close to what you got from snuff or tobacco use.

Your actual dose might be different. But as a general guideline, if you use:

• More than 3 cans of snuff or pouches of tobacco per week: Start with the higher dose of NRT (the dose for people who smoke heavily).
• Between 2 to 3 cans or pouches per week: Start with the moderate dose.
• Less than 2 cans or pouches per week: Start with the lowest dose.

If you’ve decided to try NRT, discuss your dose with a health care provider before you quit tobacco.

Smokefreevet has an online calculator that suggests NRT dosing for people who use smokeless tobacco. The suggested dosing is based on how much tobacco you use and when you place your first dip. Make sure you choose the Dip or Chew Tobacco tab.