What is Nicotine Replacement Therapy or NRT?

Dazed and Confused about Nicotine Replacement?

Quite simply, nicotine replacement therapy seeks to replace the nicotine a smoker receives from a tobacco cigarette with a controlled dosage of nicotine from an alternative device. That device could come in the form of a chewing gum, a lozenge, an inhaler, a spray, cream or transdermal patch (aka “the patch”).  In essence, these devices transfer one’s smoking addiction to a smoking cessation addiction in that the underlying cause of nicotine addiction, namely the neurological and biological changes to the smoker’s brain is not materially altered. NRT argues that by reducing the harm of tobacco use, smokers can find relief via a controlled dosage of the drug while they adapt to life without cigarettes.

How are NRT success rates measured?

Nicotine Replacement Therapies are measured against quitting “cold turkey.” In other words, all the percentages you hear and see are measured against you ability to do it on your own without various gums, patches, inhalers and lollipops.

How successful are NRTs?

It depends on whom you ask and how much they’ve been paid to conduct the research trial. The rule of thumb is that about 15-20% of users of the various NRT products will have ceased using tobacco products 12 months after starting the NRT regimen. Or put another way, NRT fails its consumers 80-85% of the time. When you look out 24 months, your odds dim even further.

Once a smoker, always a smoker?

Old dry Cuban smoking an old dry Cuban

Due to the high failure rates of NRTs, once smokers start NRTs, they continue to rely on NRTs again and again over the years. One way of thinking about NRT is that it simply intermediates the nicotine addiction process and proceeds to siphon off even more of a smoker’s income. If one were to consider the “Life Time Value” of a smoker, one would have to calculate their total purchases of tobacco cigarettes plus their on-again/ off-again efforts to quit. Given that smokers who attempt to quit are routinely advised to use these pharmacological products by their physicians, nurses, and cancer associations, it is clear that there is a big business to be had in selling products that statistically don’t deliver results. What NRTs do deliver, however, are better odds. But better odds are no guaranty. Moreover, even if you are able to quit for 6 to 12 months, there are still very good odds that you will return to smoking. And then, of course, return to NRTs. This is a revolving door that manages to secure billions and billions of dollars for all involved – including ever-rising state tobacco taxes and sales tax revenues on these products.

Can I still quit “Cold Turkey?”

Of course you can. And it’s cheaper. But be advised, you need support. That support can come in many forms, but you should recognize that what you are attempting requires a thoughtful plan. You should always consult health care provider before starting any regimen such as this. That being said, many people each year do just that. And you can too.

The Dope on Dopamine

Are tobacco cigarettes eating your brain?

Nicotine, like cocaine, heroin and marijuana, elevate levels of the neurotransmitter dopamine in the brain. Dopamine is what produces the sensation of reward and pleasure, in other words “the high” that people report feeling. It is this change in dopamine that is a fundamental characteristic of all addictions.

The graph shows resting dopamine levels in non-smokers versus smokers. What we can conclude from this image is that smokers seek nicotine as a way to replace a perceived loss in dopamine levels. In other words, the “high” from smoking is actually the perception of “return to relative normal.” In other words, smoking tobacco may very well rob the brain of critical pleasure chemicals over time. This creates in the user a sense of loss. That sensation creates a “craving” which is nothing more than the perceived need and real desire to return to where the smoker once was (e.g. dopamine balance.)

Positron Emission Tomography (PET) scan of the brain of a smoker and that of a non-smoker. We can see that tobacco smoking causes a tremendous decrease in dopamine levels.  Nicotine affects a specific enzyme responsible for breaking down dopamine, called monoamine-oxidase-A (MAO-A). Nicotine, therefore, decreases MAO-A which prevents dopamine from naturally breaking down in the human brain. This temporary halt to the dopamine reuptake process results in a temporary increase in dopamine levels of the cigarette smoker (e.g. the high). This may be an important reason that smokers must continue to smoke as this form of nicotine delivery is critical for smokers in order to sustain their desired dopamine levels. Another way of thinking about this is that smokers don’t smoke because they want to smoke; they smoke because they have to smoke. In order to function normally, smokers must rely on nicotine as a tool to regulate dopamine levels in their brain. It is possible that something within the tobacco is working in conjunction with nicotine to accelerate the process whereby dopamine production is turned off in the brain. Under this hypothesis, the brain is

fooled into ceasing its normal functioning and turns to nicotine as the device to bring back that sensation of “normal.” This attachment to an outside agent produces, among other things the basis for addiction and the “cravings.” Those cravings are very real. The brain is being starved for vital chemicals it relies on for feelings of happiness and fulfillment. By shutting off the dopamine production process, humans become dependent on anything that helps them return to that state (e.g. chocolate, cocaine, alcohol, exercise, etc.)  This dependency induces in the smoker a constant state of anxiety as the locus of control is now outside the person itself. For the smoker, the cigarette becomes a talisman, an ogre, a tyrant, and a savior all in one.

What do doctors say about NRTs relative to other options?

“When asked about nicotine replacement treatment products available, physicians should note that, despite low compliance with the recommended dose of the spray and inhaler and differences in product ratings, overall, there are no notable differences between the products in their effects on withdrawal, discomfort, perceived helpfulness, or general efficacy.”

Archives of Internal Medicine, September 1999, Vol. 159, No. 17, Randomized Comparative Trial of Nicotine Polcrilex, a Transdermal Patch, Nasal Spray, and an Inhaler.

While this is not a recent study, it is high unlikely that the human brain and the nicotine molecule have changed all that much in the advancing years. Now, it is also important to note, that all doctors have not weighed in on the issue. And the above quote, while very reputable, is not the last word on the subject. It is not our goal to suggest that NRTs are not effective. Certainly they can be. But what it important to remember here is that NRTs are only a tool, not a guaranty of smoking cessation. To think that the process will be easy or that one is somehow free of tobacco simply because one is chewing gum or wearing a patch is a self-delusion.

Many of alleged problems with NRTs lie with the smokers themselves.

I can quit any time I feel like it.

One of the greatest challenges with NRTs is not the device itself. It is the person and their mindset when beginning a smoking cessation regimen. There is a belief that if “I’m taking a pill or using this device, the product will do the work for me.” That is simply not true. If a lack of self-agency and self-discipline got you into this mess, it is unlikely that it will get you out. In other words, you get what you put in. If you think that you can simply pop a pill and wake up free of the smoking addiction, you are terribly mistaken. Smokers need to take responsibility for their actions and themselves. They need to understand and appreciate just what they’ve done to themselves and how difficult this will be to undo. It is not impossible, but it is challenging. In a society that has become accustomed to quick fixes and instant gratification, it is not surprising that people would become easily discouraged and give up. That said, the NRTs themselves help set unreasonable expectations by not clearly stating that your odds of nicotine cessation stand at 90% failure. If there were a phrase that best describes the likelihood of smokers to achieve full cessation after 2 years, it would be “Don’t Bet On It.” But you don’t have to be one of the statistics. The challenge is a mental one as much as it is a physical one. Beginning the cessation process with the right plan, the right tools and the right support can make all the difference in the world. And in fairness to the NRT products, there is no substitute for hard work, conviction and intelligent planning.

Which is better Cold Turkey or Nicotine Replacement Therapy?

The answer is – it depends on who you ask. If you talk to those who could quit “cold turkey” (CT) they’ll tell you it was their will power and their determination that saw them through. They will likely crow about their unique powers of mental fortitude and convince you that no one needs an NRT and that “if it worked for me, it will work for you!” That nonsense is every bit the hucksterism that CT advocates accuse NRT companies of promoting. Truth rarely comes in black and white. People are unique and need different things at different times. That said, however, a rather damning report issued in 1996 called the California Tobacco Study found that 6 months after of commencing a smoking cessation regimen, there appeared to be no statistical difference between those who quit CT or those who relied upon NRT. But what the report cannot tell you is WHY that is the case? Is it because NRTs don’t work or is it because people lack will power, discipline, support, etc? If the success rate is the same, the question then becomes, which process will make you feel more at ease? Which one is better suited to your lifestyle?

What does the current research on NRT effectiveness say?

In reviewing the literature it appears that NRTs are slightly better at helping you quit tobacco than were you to do it entirely on your own. However, here’s an important point: eventually, every smoker has to quit nicotine cold turkey. In other words, even with the gums, lollipops, patches, popsicles, and inhalers eventually there comes a time when you have to take off the training wheels and live without the crutch. You will either quit tobacco or quit the NRT. But either way, you have to let it go. And for that, you still need support. You need determination and you need a plan. Anyone promoting a method has a financial motive behind them. Whether they are selling a book, conducting therapy sessions or pushing patches, no one gets away from cigarettes for free. With that in mind, pick a plan that is right for you, find a group, read up on what is going on in you brain when you try to quit. Prepare yourself for the challenge just like you would any sporting event. Warm up to the challenge. Then, take action.

It would be an enormous disservice to the quitter to say “X product is better than Y product” or “Y method is better than Z” method. The truth is that however you find your way to tobacco cessation is the right way. Ultimately, the goal should be about ridding yourself of the 4,000 mysterious chemicals within tobacco cigarettes. Anything that helps reduce that harm and the harm second hand smoke causes others is a worthwhile goal.

Can I mix and match drug therapies and NRTs (e.g. Zyban and Nicorette?)

Recent research seems to support that this can work well for certain people. Again, whenever you consider a cessation program you should talk this over with your health care provider, examine your unique health risk profile and then begin a regimen that suits your needs and lifestyle. Drug therapies on the market currently include therapies such as: Zyban/Buproprion, Habitrol, Chantix and/or vaccines. In each of these cases, you should do your research, come prepared to discuss with your doctor your questions and establish a program that fits your unique situation. Remember: primary care physicians are not addiction medicine specialists. Work with your primary care provider to understand the latest research on this subject. Also keep in mind, depending upon you age, gender and prior medical history some of the drug-based therapies may not be right for you. As always, do your homework and consult your doctor.