What are the risks of smoking?
Smoking is the major cause of lung cancer. In Colorado, it accounts for 75% to 85% of lung cancer deaths. More deaths in the United States are attributed to cigarette smoking each year than to any other preventable cause. About 70% of people who smoke cigarettes want to quit smoking. If they stop, they could potentially gain up to 10 years of life.
But quitting is difficult – people who attempt to quit smoking make an average of about six attempts before abstaining long term.
Why is smoking so hard to quit?
When you smoke tobacco, you get an incredibly rapid increase in nicotine into your system. Nicotine binds to certain receptors in your brain, called alpha-4 beta-2 nicotinic receptors. That releases dopamine, a molecule that gives you a positive, rewarding feeling. As you continue to smoke, you get more of these receptors. You become dependent, so when you are not smoking and your blood nicotine levels drop, you start to get withdrawal symptoms.
Those symptoms include nicotine cravings, but they also include non-specific things like irritability, change in appetite, sleep trouble, and mood changes – things that people might not recognize as nicotine withdrawal. People may want to cope with these feelings by smoking. So it’s a cycle of addiction.
What is nicotine replacement therapy and how does it work?
NRT is designed to treat withdrawal, making it easier for people to change their behavior around smoking. It replaces some of the nicotine you used to get from cigarettes. The nicotine binds to those alpha-4 beta-2 nicotinic receptors, helping to keep you from experiencing withdrawal when you go longer and longer without having your regular tobacco product.
NRT comes in various forms. What are they?
Basically there are two buckets. One is the nicotine patch, which is what the COE program is distributing. It’s super-easy to use. You put it on your skin for 24 hours and you absorb the nicotine through your skin. The patch gives you a very slow rise in nicotine levels, slower than you would get from a cigarette. It may take an hour to get up to a therapeutic level, and then that level stays steady for the whole day you’re wearing it.
Then there are several short-acting types, such as gum, lozenges, nasal sprays, and oral inhalers, which mostly get absorbed through the tissues of your nose and mouth. They increase your nicotine levels much faster than patches – 10 to 20 minutes instead of an hour. So, if you’re feeling withdrawal symptoms, you get some quick relief. But they don’t last as long as patches. The nicotine levels start to go down within minutes as well.
These two types of NRT can work well together. The patch will give you a steady dose to keep you from getting withdrawal symptoms during the day, and then you also have something that’s faster acting you can take when you get a craving or you need a little more help.
Patches, gum, and lozenges usually are available over the counter. For nasal sprays and inhalers, you’ll need a provider’s prescription.
Screen shots of the 2Morrow Health app, which allow qualified users to apply for free nicotine replacement therapy patches.
You’re still getting nicotine with these therapies, so how are they different from tobacco products?
For one thing, you’re not getting the harmful chemicals you get from cigarette smoke. Also, these are FDA-approved medications that are specifically designed for smoking cessation, in contrast to cigarettes or other tobacco products that are designed to promote repeated use. Nicotine replacement therapy is designed to treat your withdrawal symptoms, but not to keep you using it long term.
Do dosages of NRT change over time?
With the patch, you start out on a dose based on how many cigarettes you smoke per day to match your withdrawal needs. Over time, as you’re going longer without smoking or cutting back, you can step down the dose until, ideally, you get all the way off. The typical course is 12 weeks.
Lozenges and gum come in two strengths, based on your level of dependence. The packages have recommendations for how many you should be consuming in a day to treat your withdrawal. Over time, you should find yourself needing it less and less, so you taper off. The inhaler and nasal spray only come in one strength.
Several of these therapies are available over the counter, but is it better to use them while consulting a provider or getting some other kind of support?
NRT products work better when they’re paired with behavioral support, so if you’re talking with your provider, you can get referred to your local cessation services, like we have at UCHealth for all our care lines, offering multi-session counseling. Digital behavioral programs are another evidence-based option, such as the acceptance-commitment therapy app, 2Morrow Health, that the CU Cancer Center COE office makes available. Or you can get a referral to Colorado QuitLine, a free service which also can provide free NRT products. Pairing that counseling support with NRT will work better than just the NRT alone.
Behavioral support can help you gain behavioral skills to change smoking behavior. As I mentioned, when you smoke you get a dopamine reward, so people, over time, start to associate the things they’re doing before they smoke with that reward, which makes it harder to change the habit. If you’re used to having a cigarette when you’re stressed out, you might need some skills to figure out how to cope with that stress without reaching for a cigarette.
How effective is NRT?
We have hundreds of cessation trials that have tested all our different treatments, and NRT products have the most evidence and science behind them because they've been around the longest.
Generally, the tobacco cessation pharmacological therapies roughly double the chances of quitting. Single-form NRTs are a little less effective than that – about a 55% increase in your chances of quitting. If you combine them – let’s say a patch with a lozenge – it increases effectiveness by another 25%. And if you add behavioral counseling on top of that, you get yet another effectiveness boost.
What other tools are available to help people stop smoking?
The other prescription options we have are varenicline and bupropion. They have both been around for about 20 years and roughly double your chances of quitting. We also have good data on the effectiveness of behavioral support; quit lines; and app-based, acceptance-commitment therapy like 2Morrow Health.
What do you usually recommend for someone who wants to quit smoking?
My first-line recommendations for smoking cessation usually are either varenicline or two forms of nicotine replacement therapy – the long-acting patch every day plus a short-acting form for cravings, along with behavioral support.
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