Nicotine Drugs Used to Break Cigarette Habit : Doctors Employ Gum, Nasal Spray, Skin Patch to Try to Wean Smokers From Their Addiction
Quitting cigarettes “is like a divorce,” according to Nina Schneider, an experimental psychologist who has studied the effects of smoking for 14 years. “Some people can just walk away, but for many people the symptoms are severe,” she said.
But with many smokers expected to file for their nicotine divorce on Thursday, when the American Cancer Society sponsors its Great American Smokeout to encourage quitting, there is a new kind of alimony that can ease the painful separation from cigarettes: an ever-growing array of products designed to alleviate the symptoms of nicotine withdrawal.
Doctors and smoking experts say that these products may provide an extra boost in the battle against cigarettes. But some worry that smokers may be trading one addiction for another, and all warn that quitting cigarettes is still a hard fight.
Nicotine Gum
Available in the United States since March, 1984, is Nicorette, a chewing gum laced with nicotine that releases the drug through the lining of the mouth. Other smoking cessation tools designed to alleviate nicotine craving include a nicotine patch that would release the drug into the skin and nicotine nasal drops. Both are now being tested and may be available in the next few years, according to Schneider.
“There is not a single researcher in the U.S. or in the world who does not accept that (smoking) is drug abuse,” said Schneider, who has a doctorate in experimental psychology and is a researcher at UCLA and the Veterans Administration Hospital in Los Angeles.
The classic symptoms of nicotine withdrawal, Schneider said, include irritability, hostility, anxiety, panic, increased hunger, restlessness and a craving for cigarettes. Physical symptoms also may include neck and back pain, headaches, gastrointestinal disturbances and sweating, she said, adding, “Some people get canker sores from the stress.”
Nicotine, which speeds to the brain in an average of seven seconds, is the only known addictive agent in cigarettes, Schneider noted. And, she said, “the faster you get a drug, the more addicting it can become.” Thus, she said, “the heroin addicts and alcoholics at the VA Hospital found it harder to quit cigarettes (than heroin or alcohol). The seven-second hit of nicotine to the brain is faster than shooting heroin.”
Paired with a stop-smoking program that teaches coping skills, Nicorette “doubles success rates,” said Schneider, who conducted the first U.S. study on the gum. Other studies since then have confirmed her findings, she said.
Success Rate Improves
“From acupuncture to hypnosis to Schick,” she said, the success rates before Nicorette, meaning the percentage of ex-smokers who have not started smoking again after a year, were about the same--20%. With Nicorette and a program that teaches coping skills, Schneider said, success rates are about 40%. But she warns that Nicorette “mustn’t be perceived as a cure-all.”
Because the psychological addiction to cigarettes is so strong, “even if you are given a weaning tool, you still have to learn to go without puffing on a cigarette 200 to 400 times a day,” she said. And because using nicotine to withdraw from cigarettes “is sort of like hair of the dog,” she said, “there is a little bit of fear of dependence.”
She added that smokers should stop smoking completely and only chew the gum when they decide to quit. The gum is meant to act as a pacifier for the first few weeks when the smoker is experiencing severe nicotine withdrawal. After that, she said, the gum should be used less frequently, and then not at all.
Stephen Dibble, head pharmacist at Mission Medical Pharmacy in Mission Viejo and past president of the Orange County and the California Pharmacist Assns., said that over-the-counter gums and lozenges containing nicotine have been available for years, but they generally contained a lower dose of the drug than Nicorette and none was very effective. Nicorette, he added, is the only nicotine withdrawal product approved by the U.S. Food and Drug Administration because it has a higher dosage of the drug and requires a doctor’s prescription.
Schneider said that success rates could be three or four times higher (than 20%) with nicotine gum if it were used correctly. Many people see that Nicorette has two milligrams of nicotine, about twice the average dosage of a cigarette, and don’t want to chew too much, she said. But because of the way the nicotine in the gum is absorbed, it actually provides a lower dosage (about a third or a fifth of the amount of nicotine in a cigarette), and people generally do not chew enough.
Because the nicotine in the gum is absorbed through the lining of the mouth, it takes a few minutes to reach the brain, as opposed to the seven seconds of cigarette smoke, she said. “The gum is a two-barreled weapon,” Schneider said, because it eliminates the smoke of cigarettes and provides a lower dose of nicotine at a slower rate, creating a weaning effect.
The gum was developed 14 years ago at LEO laboratories in Sweden and is distributed exclusively by the Cincinnati drug company Merrell Dow, she said.
Merrell Dow has sold 5.5 million packages of Nicorette to 2.5 million smokers in the last 18 months, according to Charles Rongey, the company’s manager of public relations. A box of 96 pieces sells for about $20 at pharmacies, Rongey said.
W. James Nethery, president-elect of the California division of the American Cancer Society and past president of the Orange County chapter, said the Cancer Society has been watching Nicorette “with interest” but does not endorse any product or company. “I really question the use of anything with nicotine,” said Nethery, who is a dentist in Santa Ana.
Tar Causes Cancer
Tar is considered the primary factor in cigarette smoke that causes cancer, and the carbon monoxide in smoke is linked with both heart disease and cancer, Nethery said. But he added that nicotine is the major link between cigarette smoking and heart disease.
While researchers say it is possible to substitute an addiction to Nicorette for an addiction to cigarettes, the gum does not contain any of cigarettes’ other harmful ingredients.
Dr. Richard LeVine, a cardiologist with a private practice in Santa Ana and an assistant professor of medicine at UCI Medical School, said he has prescribed Nicorette to more than 100 patients who have heart disease or are at high risk for heart disease and want to quit smoking. His patients who have used the gum to quit “almost invariably need just one box,” he said.
Nicotine “goes through your whole bloodstream” and causes a constricting of blood vessels, according to Debbie Mahood, director of smoking education at the Orange County affiliate of the American Lung Assn. After smoking one cigarette, “your pulse will go up an average of 10 beats a minute, and your blood pressure goes up an average of 20 points,” said Mahood, who is also a health-science lecturer at Cal State Long Beach.
Nicotine also “increases the tendency to have irregular heartbeats,” LeVine said. He does not prescribe the gum for people “with high blood pressure or high irregularities of the heart.”
LeVine said that when using Nicorette, a smoker should follow the directions on the box and “chew one piece at a time and very slowly. Once you feel a tingling in the gums, you stop and just let it sit in your mouth.”
If a person chews too much Nicorette or chews it too quickly, he may experience nausea, hiccups, a burning sensation in the throat or upset stomach. “If you take a whole bunch of the gum, for example 20 pieces (at one time), it could be lethal,” he said. “Nicotine is a potent poison.”
A few of LeVine’s patients have become addicted to Nicorette, he said. “I had one patient who was able to stop smoking but was chewing 25 to 30 pieces of gum a day,” LeVine said. “Every time he cut down on the gum, he wanted to start smoking again.” Once the patient stopping using Nicorette, he did begin smoking again, LeVine said.
Attitude Is Important
If a smoker “is psychologically ready, it (Nicorette) will help,” LeVine said. The most important thing a smoker must do to quit, however, “is think of himself as a nonsmoker,” said LeVine, who himself is a former smoker.
Dr. Ray Casciari, a pulmonologist at the Pulmonary Consultants of Orange County Medical Group Inc. in Orange and a first vice president of the Orange County Lung Assn., said that the consultants’ group runs a stop-smoking clinic that has a 66% success rate after one year with patients who use Nicorette. The addiction rate to Nicorette, people who are still chewing the gum after a year, is 7%, he said.
Before the clinic, Casciari estimates his success rate “by just telling and scaring” people to quit cigarettes was about 5% to 10%.
He said he might not recommend the gum for people with ulcers or jaw problems. Some patients have reported getting headaches, sore gums and flushing, Casciari said.
“Nicotine in and of itself is not the cause of cigarette-associated lung disease,” he said. For patients with emphysema, lung cancer, bronchitis and other lung-related illnesses, he said, “I would rather they chew the gum than smoke.”
Some smokers enrolled in the Lung Assn.’s “Freedom From Smoking” class have used Nicorette gum, Mahood said. “There is a place for it for the heavy smoker, someone who smokes a pack and a half a day,” she said.
If a smoker in the class wants to use it, he will have to get a prescription from his personal doctor, she said. “We (the Lung Assn.) can’t endorse any product, but we’re for anything that will help you quit,” she said.
A smokeless cigarette designed to deliver a nicotine vapor, produced by Advanced Tobacco Products Inc. in San Antonio, is being sold in Austin and Dallas and may be available in the Los Angeles area in about six months, according to company Chairman and Chief Executive Gerald R. Mazur. The cigarette, Favor, is being marketed as a way to smoke in nonsmoking areas, such as theaters, airplanes and offices, Mazur said.
“We don’t say it’s good for you,” Mazur said. And Favor is not intended to help people quit smoking, he said.
No FDA Approval Needed
But Schneider said the cigarette may be a cessation tool, depending on how fast it delivers nicotine to the brain. Advanced Tobacco Products has not allowed outside researchers to test Favor for its usefulness to quitters, she said, and Favor is not approved by the FDA. (Tobacco products do not need approval by the government, “unless the seller made a claim that it had a medical effect, such as reducing the craving for nicotine,” FDA spokesman Edward Nida said.) Mahood of the Lung Assn. said a smokeless cigarette could be “a plus” for nonsmokers. “My first concern is with the nonsmoker. If someone works (near) a smoker all day, the nonsmoker’s lung will show the effects of a light smoker’s lung.”
A smoking cessation tool that is being developed at the psychopharmacology lab at the VA Hospital in Los Angeles is the transdermal nicotine patch, a Band-Aid-like patch that is attached to the underside of the forearm and releases nicotine into the blood system, according to researcher Dr. Murray Jarvic, who has studied smoking for 15 years. A smoker would put on the 1-inch-by-1-inch patch early in the morning, leave it on all day and throw it away at night, Jarvic said.
Several drug companies have made inquiries about the patch, and it could be on the market as early as Jan. 1, said Jarvic, who developed the patch with researcher Jed Rose. It also could take years for it to be released, Jarvic said. “It depends on what the Food and Drug Administration wants us to do,” he said.
Hospitals for years have used transdermal patches to administer drugs (among them nitroglycerin patches for heart patients), Jarvic said. “Nicotine happens to be a substance that penetrates membranes very quickly. We just use pure nicotine liquid, which passes through the skin,” he said.
In a preliminary study, 10 heavy smokers were asked not to smoke for 90 minutes and given a placebo patch one day and a nicotine patch another day, according to psychopharmacologist Joseph Herskovic, who assisted in the testing. Neither the smokers, who on the average smoked a pack and a half a day, nor the researchers knew which patch was which, Herskovic said.
Difference in Craving
Smokers reported a greater craving for cigarettes when they had the bogus patch on, Herskovic said. On a scale from 0 to 10, with 0 meaning not wanting a cigarette “at all” and 10 meaning wanting one “extremely,” the nicotine patch elicited a rating of 4 and the placebo patch a 5 1/2.
“It seemed to work,” Jarvic said, although, he added, 90 minutes was not very long for a smoker to go without a cigarette. “What really counts is how they can go without cigarettes for a whole day or month or year.”
Another possible stop-smoking product is nicotine nasal drops, being developed by researchers in England, Schneider said. The nasal nicotine solution could provide a higher level of nicotine and a faster way to get it (than nicotine-laced gum), she said. A yearlong study has shown that the solution does help with nicotine withdrawal, but the solution will probably not be available “for a good five years,” Schneider said.
Nicotine is “a most incredible drug” in that it can act as either a stimulant or a depressant, Schneider said. Some smokers use it to sustain job performance levels, she said.
“There is a lot of good evidence that smoking helps people to concentrate,” Herskovic said. People whose jobs demand a steady level of concentration, although “nothing happens, except every once in a while”--for example, truck drivers or air traffic controllers--may use cigarettes “to keep their minds from wandering,” he said.
Schneider said people who use nicotine to stay alert tend to be heavy smokers. The nasal drops could be used with the gum to help alleviate the disorientation that some people experience with nicotine withdrawal, she said.
‘Personal Friend’
Quitting smoking “is up there with the major life stresses, with marriages, divorces, deaths,” she said. Because people associate smoking with so many things, such as eating, drinking, driving and working, it can be like “a personal friend.”
And Schneider knows. Before she became a smoking researcher, she had a three-pack-a-day habit for seven years. She said she smoked high-tar, high-nicotine brands and loved to experiment with different brands. “I loved getting a fresh pack and opening it up,” she said.
She decided to quit 20 years ago, she said, when she started getting tonsillitis four times a year. She quit cold turkey after her second try. Nicotine gum would have helped her then, she said.
But even more, she wishes something to alleviate nicotine withdrawal had been around earlier. “My dad died of emphysema. I wish it were around then,” she said.
