Chapter 9

Finding Help at the Pharmacy

IN THIS CHAPTER

Bullet Reducing your cravings for nicotine

Bullet Discussing prescription options with your doctor

Bullet Dispelling common myths about medications

There are many different roads to quitting smoking or vaping. Some people try to do it cold turkey aided only by their own sheer stubbornness and willpower. Unfortunately, most quitters take this route. Without support from educational materials, brief counseling, or medication, only about 5 percent of those flying solo will remain smoke free in six months. The vast majority of cold-turkey, on-their-own quitters will relapse within a week.

Many resources are available to help people quit smoking, and we introduce you to these resources in this book. We outline practical ways of challenging thinking, getting through cravings, and changing activities that will help you quit in Chapter 10. Chapter 11 describes some of the various technological strategies that can support efforts at quitting.

In addition, we recommend that most people who are trying to quit consider talking to their healthcare providers about one of the options for replacing nicotine and managing cravings. That’s because research clearly states that using prescription medications significantly increases the odds of successfully quitting smoking.

But taking medication is not for everyone. In this chapter, we describe the pharmacological options for quitting smoking now available. We give you the lowdown on side effects and success rates so that you can make an informed decision in consultation with your healthcare provider.

Replacing Nicotine

Nicotine makes most people feel good. It lights up the pleasure center in the brain and simultaneously relaxes and increases alertness. It’s no wonder that nicotine is one of the most addicting of all drugs. But people who smoke, chew, or vape don’t seem to get the same kind of euphoric high that other drugs like cocaine or heroin produce. So, why is nicotine so addictive?

The answer comes from the brain, which quickly learns to depend on nicotine. The fact that most users of nicotine use it repeatedly throughout the day increases this dependence. It has also been found that nicotine increases the pleasure of other activities, such as listening to music or watching videos. So, smokers or vapors who fear that life won’t be as pleasurable without their crutch are sadly correct, but only to a point. That makes motivation even more difficult to maintain for those who want to quit. Replacing nicotine may help.

But if you don’t replace the nicotine that your body craves, you’ll probably experience nicotine withdrawal. That can be a rather unpleasant experience for many. Nicotine withdrawal symptoms often include the following:

  • Anxiety
  • Digestive distress
  • Headaches
  • Intense cravings
  • Irritability and frustration
  • Mood swings
  • Restlessness
  • Sore throat and increased coughing
  • Sweating
  • Tingling in the hands and feet

The good news is that you don’t have to experience most of these symptoms if you turn to nicotine replacement therapy (NRT). Experts agree that NRT is one of the simplest and most successful aids to quitting smoking. In fact, NRT increases the rate of quitting by at least 50 percent. This finding has been replicated many times. NRT helps people manage the withdrawal symptoms so that they can concentrate on the emotional aspects of quitting. Those who are particularly dependent on nicotine (heavy smokers) are most likely to receive benefits from NRT.

Tip NRT has been around for decades. For most healthy adults, it’s safe to use. People with chronic diseases (such as heart disease), women who are pregnant or considering getting pregnant, and teens should talk to a healthcare provider before starting NRT. Keep in mind that, in almost all cases, NRT is far safer than continuing to use tobacco because nicotine doesn’t contain most of the harmful chemicals found in tobacco.

Tip Replacing nicotine from cigarettes with safer medications will probably help with physical withdrawal symptoms. However, it does not help with deeper psychological dependence. For help with your emotions, see Chapters 10 and 11. For more help with cravings, see Chapters 17 and 18.

Using nicotine replacement therapy

The day you toss your tobacco or vaping devices is the day you can start NRT. If you’re still consuming tobacco or nicotine, it’s often recommended that you not use any NRT product. However, some people do use NRT to help them cut down. If that’s your plan, talk to your doctor. It’s possible to overdose on nicotine, but under a doctor’s direction, it’s quite unlikely.

Tip Over-the-counter NRT is usually not covered by insurance. Typically, insurance will cover NRT when it’s prescribed by a doctor. However, many states offer free or sharply reduced prices through their state-funded quit lines. To contact your state quit line, call 800-QUIT-NOW (800-784-8669). The National Network of Tobacco Cessation Quit lines will direct your call.

Surveying the drugstore shelves

The quickest and easiest way to find NRT is to drop by your local drugstore. Most of them have a good supply available for you to peruse. These do not require a doctor’s prescription. All you need to do is walk in, look around, and buy the one you want! Nonetheless, your pharmacist will gladly discuss any concerns you may have. And if you have any health concerns, it’s always best to check with your doctor. There are three major types of over-the-counter options: patches, gum, and lozenges.

Tip The great news is that NRTs all work much better than trying to quit without extra help. Which one you decide to try is really a personal choice. We explain how they work, any special considerations, and side effects in the following sections.

Warning Keep all nicotine products such as lozenges and gum away from children and pets. Because of their lower bodyweight, overdoses can occur much more easily.

Nicotine patches

Nicotine patches have been well researched and found effective as an aid to quitting smoking. In a nutshell, they work! Patches work by continuously delivering a small amount of nicotine through the skin and into the bloodstream. You put a patch below the neck and above the waist (usually on the chest or upper arm) on a clean, dry, and hopefully hairless area!

Tip Don’t put the patch in the same area of the body every day. Move it around to minimize irritation.

Patches deliver nicotine over two different durations — 16 hours and 24 hours. The 16-hour patch usually has fewer side effects than the 24-hour version. However, some people find that they need the full-day, steady dose.

Nicotine patches also come in different strengths. If you’re a heavy smoker, you’re likely to want the higher-dosage regimen, generally starting with about 20 milligrams of nicotine per patch. Those who smoke somewhat less, are likely to find that the weaker starting strength of about 15 milligrams suffices. Typically, patches are used at the starting dose for four to six weeks; then a lower dose is used for two weeks, followed by a final two weeks at an even lower strength. Patches are approved for use for a total of five months; however, some people use them longer.

Side effects of nicotine patches include

  • Redness and itching at the application site
  • Strange dreams or problems sleeping
  • Racing heartbeat
  • Dizziness
  • Headache
  • Nausea
  • Muscle discomfort

These side effects can occur because the dosage is excessive for one’s needs. Often, decreasing the dosage can help. Twenty-four-hour patches sometimes also cause sleep problems. Try switching to 16-hour patches if that happens. For skin irritation, trying another brand may alleviate the problem.

Feel free to experiment with different dosages and patch durations. Chris’s story (see the nearby sidebar) illustrates a successful ex-smoker who thought he’d never succeed.

Warning If side effects, such as a racing heart, are disturbing, talk to your doctor about whether to lower the dose, change to another type of NRT, or stop it altogether.

Warning Do not use a heating pad or heat lamp on the skin area covered by the patch. Heat will speed up absorption of the nicotine and possibly result in an overdose.

Tip It’s easier to give up the patch than smoking cigarettes because you only put the patch on once per day rather than taking puffs off cigarettes hundreds of times per day.

Nicotine gum

Nicotine gum is used for a fast-acting nicotine replacement. It’s absorbed through the mucous membrane of the mouth and acts faster than patches on the skin. Many smokers trying to quit use it for especially urgent cravings. It’s also recommended for people who chew tobacco because it gives them a partial replacement for the sensations involved in chewing, which have become highly pleasurable over time.

Avoid eating or drinking for at least 15 minutes before and during use of nicotine gum. Chew the gum slowly until you feel a slight tingling sensation, similar to what pepper induces. Then keep the gum between your cheek and gums until the flavor and tingling fade. Then chew again until the sensation returns. Continue this pattern for about 20 or 30 minutes.

Warning Don’t chew the gum continuously. Be sure to stop chewing when you first detect tingling or a burst of flavor. That way, the nicotine will be slowly absorbed into your mouth’s mucous membrane. If chewed continuously, the nicotine will be delivered from your saliva directly into your stomach, resulting in an upset stomach.

Nicotine gum comes in two strengths — 2 milligrams and 4 milligrams. For those who are heavily dependent on nicotine, the stronger dose is usually recommended to start. The dose for the first six weeks is usually one piece every one to two hours, whether you’re starting with the 2-milligram or 4-milligram regimen. The maximum recommended dose is never more than 24 pieces of nicotine gum a day. After six weeks, the frequency and strength are usually decreased gradually. A typical goal is to stop the use of gum after three months. Consider sugar-free, non-nicotine gum after that.

Nicotine gum sometimes produces a few side effects, including the following:

  • Bad taste
  • Mouth sores or throat irritation
  • Nausea
  • Jaw discomfort
  • Racing heartbeat

Warning If you have a racing or irregular heartbeat, stop using the product until you talk to your doctor.

Like nicotine patches, evidence is strong that nicotine gum provides a substantial aid to those trying to quit smoking, and there’s every reason to believe that it will work equally well for quitting vaping nicotine or smokeless tobacco products.

Nicotine lozenges

A nicotine lozenge is like a hard candy that releases nicotine as it dissolves in the mouth. Lozenges should be sucked, not chewed or swallowed. It takes about 20 to 30 minutes for them to fully dissolve. While sucking them, it’s best to move them around in your mouth and between your cheeks and gums. As with gum, do not eat or drink 15 minutes before or while using them.

Tip As with the case for gum, people who are quitting smokeless tobacco may find lozenges particularly helpful for replacing pleasurable oral sensations.

Lozenges typically come in two strengths — 2 milligrams and 4 milligrams. Like nicotine gum, those with a heavier smoking history usually start with the higher dose. The maximum dose per day is 20 lozenges. The recommended schedule for the first six weeks is usually one every one to two hours. After six weeks, the dose is usually reduced, and the frequency is gradually tapered. You should not suck on more than one lozenge at a time, nor should you use them one right after another. Discontinue lozenges by around 12 weeks.

Possible side effects of nicotine lozenges include the following:

  • Digestive distress
  • Sore throat and coughing
  • Headaches
  • Insomnia
  • Racing heart rate

Warning If you experience an irregular or racing heartbeat or other disturbing side effects, check with your doctor.

Checking for nicotine replacement therapies behind the counter

Nicotine nasal sprays and inhalers need a doctor’s prescription. Drugs are prescribed because they’re considered potentially harmful and their use needs to be supervised by a healthcare provider. In order to take a prescribed drug, you need to have a consultation with a healthcare provider, so if you’re interested in one of these products, make an appointment with your doctor.

Nicotine nasal spray

Nicotine nasal sprays are like other nasal sprays in terms of how they’re used. This type of NRT works faster than any other NRT.

Warning An important caveat is that because nicotine nasal spray works so well and so quickly, it may be more addictive than other NRTs.

This product should be used as directed by your healthcare provider. Generally, a dose consists of two sprays, one in each nostril. The maximum dose per day is 40 doses of two sprays each. Nasal sprays should not be used for more than six months.

Side effects of nicotine nasal spray include those caused by other NRT’s such as racing heart, headache, and stomach upset. In addition, they have the potential to cause

  • Irritation in the nose
  • Sneezing
  • Throat irritation
  • Coughing
  • Watery eyes

Some or all of these side effects may dissipate over a couple of weeks. However, you should contact your healthcare provider for any particularly disturbing side effects, such as racing heart rate, or if other side effects do not fade.

Warning Because nasal spray bottles contain enough nicotine to harm children or pets, be sure to keep them out of reach. If skin contact occurs, the area should be thoroughly washed with plain water. Call the American Association of Poison Control Centers with any concerns at 800-222-1222.

Nicotine inhalers

Nicotine inhalers are the NRTs that are most like smoking a cigarette. Just like a cigarette, you inhale, and then nicotine is absorbed in the mouth and throat. Unlike a cigarette, there is no burning, and the nicotine does not go into the lungs. Former smokers like nicotine inhalers because they closely mimic the experience of smoking. Nicotine inhalers are also the most expensive of all the NRTs. However, insurance may cover some of the cost.

The nicotine inhaler is available in a kit that contains a thin tube and cartridges containing nicotine. You put the cartridge into the tube and inhale like a cigarette. Each cartridge supplies about 4 milligrams of nicotine, but only 2 milligrams are absorbed. That comes to about the amount delivered by a typical cigarette. Cartridges last for about 20 minutes of inhaling. The maximum dose is 16 per day, but people generally use less than 10. You should stop after 12 weeks of use.

Remember Stop smoking before you start using inhalers. Don’t drink coffee, juices, or soda 15 minutes before and 15 minutes after using an inhaler. During the first week, you should use at least six cartridges per day. You may taper off over the course of treatment.

Side effects of nicotine inhalers include

  • Mouth and throat irritation
  • Coughing and runny nose
  • Upset stomach

As with other NRTs, excessive nicotine can cause headaches, rapid heart rate, or digestive distress. Talk to your doctor if you experience these symptoms and they fail to resolve.

Warning The cartridges have enough nicotine to harm children and pets. Take special care to store and dispose of cartridges so they can’t fall into the wrong hands — or, for that matter, paws.

Combining nicotine replacement therapies

We know at this point, that NRTs help people quit smoking. What about combining more than one NRT? For example, some people like the patch, but still experience sharp cravings from time to time during the day. Those people often turn to nicotine gum or lozenges to deal with those cravings.

Considerable research supports what these people intuitively figured out. Specifically, studies show that using the patch with “emergency” NRTs such as gum, lozenges, nasal sprays, or inhalers increases the odds for successful smoking cessation by up to a third.

Warning If you choose to combine more than one type of NRT, be aware of the symptoms of excessive nicotine (such as headache, dizziness, rapid heart rate, or stomach upset). Decrease the amount of NRTs you’re taking and consult your healthcare provider.

You may worry that depending on NRTs is just another form of addiction. After all, both smoking and NRT’s deliver nicotine to your body and nicotine is truly addictive. Olivia struggled with this worry. Her story is in the nearby sidebar.

Remember Few people find NRTs as fully satisfying or addictive as consuming tobacco. The more important point is that NRTs do not contain the literally thousands of chemicals found in tobacco and especially burned tobacco. They should be viewed as a temporary bridge to transition you from tobacco to nicotine to a full-blown ex-smoker. The timeline is up to you.

Prescribing Medications for Coping with Quitting

Way too many people still believe that addiction is a sign of weakness or some type of character flaw. Because of that belief, way too many people don’t get the help and support that they need. They feel ashamed and weak, too embarrassed to admit they would like to quit, but can’t. They think they should go it alone and, thus, avoid talking about it.

Yet, many tobacco users can find relief by talking to their healthcare providers honestly about their desire to quit. There are medications that can help some people give up tobacco and nicotine that comes in any form. Asking about the medication option doesn’t label you as an addict.

When you talk to your healthcare provider about your desire to quit, be sure to discuss any medical conditions and allergies you have and any over-the-counter medications or supplements that you take. Also, be sure to tell your doctor if you’re pregnant or planning to become pregnant. It’s also imperative to come clean about any drug or alcohol use.

Tip Your healthcare provider wants you to tell the truth. Providers have been trained in maintaining a nonjudgmental stance, and most have some of their own problems of one kind or another. There is no story they haven’t heard. In the rare event that you do feel judged by a healthcare provider, try to talk about it. But if the conversation doesn’t go well, find someone else to work with.

Turning to on-label prescriptions

There are currently two medications approved by the U.S. Food and Drug Administration (FDA) for helping people quit smoking. These medications work for some but not all people with nicotine addictions. Talk to your healthcare provider about whether you may benefit from one or the other.

Varenicline (Chantix)

Varenicline helps people stop smoking by decreasing the pleasure a smoker gets from smoking (some report that it makes cigarettes taste bad) and reducing withdrawal symptoms. It does this by interfering with the brain’s nicotine receptors. Some studies have suggested that varenicline is at least as effective as NRTs and may for some people be more effective than bupropion (see the next section). This is particularly true for women smokers; however, the differences are relatively small.

You usually start taking varenicline about one to four weeks prior to quitting. Typically, the starting dosage is 0.5 milligram per day for the first four days. Then you take 0.5 milligram twice a day. Finally, it’s increased to 1 milligram twice a day. Varenicline is most commonly given for about 12 weeks, and many people choose to continue taking it for 12 more weeks to help reduce the risk of relapse.

Side effects of varenicline can be significant for some people, and it should be reported to the prescribing healthcare provider. Side effects may include

  • Nausea, vomiting, and/or constipation
  • Disturbed sleep, unusually vivid dreams
  • Increases potency of alcohol
  • Headaches
  • Depressed mood
  • Agitation
  • Suicidal thoughts and behaviors

Although it’s rare, if you have any increased depression or suicidal thoughts, you should immediately contact your healthcare provider. The story of Emma (see the nearby sidebar) illustrates a challenging side effect of varenicline.

Previously, the FDA issued a black-box warning about varenicline’s potential to increase depression, agitation, and suicidal thoughts and behaviors. However, a large study convinced the FDA to remove the black box warning because it failed to find a statistically significant relationship between varenicline and adverse neuropsychiatric events. Some researchers feel that this cancellation was premature, because the study was not large enough to detect what they believe may be a valid concern.

Warning If you or someone you care about is taking varenicline and begins to feel depressed, agitated, or suicidal, make sure to see a healthcare provider immediately.

Bupropion (Zyban)

It’s less clear how exactly bupropion helps people stop smoking. Bupropion was first and continues to be used as an antidepressant (called Wellbutrin when used for depression). It was noticed that many depressed people taking bupropion basically lost interest in smoking, making it easier to quit.

Researchers studied the effects of bupropion and found that, indeed, it appeared to interfere with nicotine’s addictive effects. Bupropion has been used successfully to help people quit smoking for decades. It appears to work best when combined with NRTs.

You should start bupropion one to two weeks before your quit day. Starting dosage is usually 150 milligrams for three days, increased to 150 milligrams twice a day. Treatment usually works within two months. If it doesn’t work by then, bupropion is generally discontinued. Treatment lasts for about 12 weeks, but many people choose to take bupropion longer then that, sometimes as long as a year.

Tip If you’re depressed, bupropion may improve your mood. However, you don’t have to be depressed to benefit from bupropion for smoking cessation. A benefit of bupropion is that it may lead to less cravings in other areas of your life, such as food or alcohol. However, there is little quality research to substantiate those claims.

Warning If you have a seizure disorder, a history of seizures, or bipolar disorder, bupropion is not likely for you. Talk to your doctor.

Bupropion, like almost all pharmaceuticals has a long list of side-effects. However only about 10 percent of those taking it need to discontinue bupropion because of these side effects. Most of these symptoms will decrease over the first couple of weeks. These side-effects include

  • Dizziness
  • Tremors
  • Insomnia
  • Jitteriness
  • Dry mouth
  • Concentration problems
  • Anxiety
  • Upset stomach and constipation
  • Rashes
  • Very small increased risk of seizures

Like varenicline, bupropion previously had a black-box warning that stated there may be an increased risk of suicidal thoughts and behavior, depression, and agitation. This was later removed based on the same study that prompted the FDA to remove it from varenicline (see the preceding section). Some researchers have questioned whether that study was robust enough to justify the removal of the warning.

Warning If while taking bupropion you experience increased depression, agitation, or suicidal thoughts or behaviors, immediately contact your healthcare provider. This may not be the medication for you.

Looking at off-label prescriptions

If you have health issues that prevent you from taking NRT or FDA-approved medication for smoking cessation or if other methods have failed, your doctor may consider another type of medication to help you quit. There are several drugs that have not been specifically approved by the FDA for smoking cessation but have been used and shown promise for individuals who have been unsuccessful with other methods.

There are two drugs that are used but have not been officially studied and approved by the FDA for this purpose. However, they are relatively safe and have been found to be reasonably effective in helping people quit smoking.

  • Nortriptyline: This drug is a much older antidepressant medication than bupropion. Limited research has found that it can be effective in helping smokers quit. Generally, people start using it for a few weeks prior to stopping smoking. Side effects include blurry vision, dry mouth, fast heart rate, constipation, orthostatic (low) blood pressure when standing up, and weight gain or loss.
  • Clonidine: This medication has been used to treat high blood pressure. Some studies have found it to be helpful for smoking cessation. It’s usually started a few days before quitting. It can be given in a pill or patch form. Side effects include fatigue, dizziness, constipation, dry mouth, and weakness.

More promising medications are on the way. Quitting any addiction is highly individual and can take many different paths. Be patient. Don’t give up. Work with your healthcare provider to explore options.

Thinking Medication Is Not an Option

There are a few reasons why certain medications are contraindicated for some people. For example, if you have a seizure disorder, some medications may not be good options. The same thing applies to pregnant or breastfeeding women, teens, and people with certain health problems.

But the more common contraindications occur in how people think and what they believe about medications. Here are some of the most common reasons that people cite for not wanting to take medications for smoking cessation and some answers to these concerns:

  • I don’t want to substitute one addiction for another. Medications for smoking cessation are not particularly addictive. You can gradually taper off these medications with many fewer problems than trying to stop smoking. They also have far less negative health effects than smoking and vaping do.
  • I prefer natural approaches to medication. Tobacco is natural but it contains numerous harmful chemicals, which only multiply when smoked. The point is to get you off of smoking or vaping. If you can do that naturally, great. But if you can’t, please consider medications or other techniques discussed in this book.
  • I’m afraid of side-effects. Smoking has side-effects, too — such as sore throat, cough, heart disease, and cancer. Side effects from medication pale in comparison. And many side-effects can be managed or go away on their own. Talk to your healthcare provider about your concerns.
  • I’m worried about the expense. You can call the National Network of Tobacco Cessation Quit Lines at 800-QUIT-NOW (800-784-8669) to obtain information about reduced-price and free options. Because most medications are a temporary bridge to quitting, the overall cost is much less than a lifetime of smoking.