Nicotine replacement therapy
Nicotine replacement therapy (commonly abbreviated to NRT) is the remedial administration of nicotine to the body by means other than tobacco, usually as part of smoking cessation. Common forms of nicotine replacement therapy are nicotine patches (which transdermally administers nicotine) and nicotine gum (which orally administers nicotine). The primary benefit of nicotine replacement therapy is that it prevents cravings in a smoker whilst allowing him to abstain from tobacco—and thus avoid the harmful effects of smoking. NRT enables the easier overcoming of nicotine addiction because it reduces the craving to smoke. The incidence of smoking after the use of nicotine replacement therapy is 1.5–2 times less than when therapy is not used.
Nicotine patches are a transdermal patch for the administration of nicotine. Nicotine gum, nicotine sprays, nicotine sublingual tablets, and nicotine lozenges administer nicotine orally. Nicotine inhalers are metered-dose inhalers that administer nicotine through the lungs and mucous membranes, especially the back of throat
Electronic cigarettes are an emerging method for nicotine administration that consists of inhalation of a nicotine containing atomized solution. Negative health affects and efficacy are still under investigation and the Food and Drug Administration reflects this attitude.
Questions over long-term effectiveness
In an online Harvard University news story article posted on Monday, January 9, 2012, by Marjorie Dwyer from HarvardScience in the Harvard Gazette, involving researchers in a study from the Harvard School of Public Health and the University of Massachusetts Boston (UMB),: "Nicotine replacement therapies (NRT), specifically nicotine patches and nicotine gum, did not improve smokers' chances of long-term cessation" ... "The study appears Jan. 9 in an online edition of "Tobacco Control" and will appear in a later print issue. “What this study shows is the need for the Food and Drug Administration (U.S. FDA), which oversees regulation of both medications to help smokers quit and tobacco products, to approve only medications that have been proven to be effective in helping smokers quit in the long term and to lower nicotine in order to reduce the addictiveness of cigarettes,” said co-author Gregory Connolly, director of the Center for Global Tobacco Control at HSPH.
In the prospective cohort study, the researchers, including lead author Hillel Alpert, research scientist at HSPH, and co-author Lois Biener of the University of Massachusetts Boston Center for Survey Research, followed 787 adult smokers in Massachusetts who had recently quit smoking. The participants were surveyed over three time periods: 2001-2002, 2003-2004, and 2005-2006. Participants were asked whether they had used a nicotine replacement therapy in the form of the nicotine patch (placed on the skin), nicotine gum, nicotine inhaler, or nasal spray to help them quit, and if so, what was the longest period of time they had used the product continuously. They also were asked if they had joined a quit-smoking program or received help from a doctor, counselor, or other professional. The results showed that, for each time period, almost one-third of recent quitters reported to have relapsed. The researchers found no difference in relapse rate among those who used NRT for more than six weeks, with or without professional counseling. No difference in quitting success with use of NRT was found for either heavy or light smokers. “This study shows that using NRT is no more effective in helping people stop smoking cigarettes in the long term than trying to quit on one’s own,” Alpert said. He added that even though clinical trials have found NRT to be effective, the new findings demonstrate the importance of empirical studies regarding effectiveness when used in the general population."
Another concern relates to the fact that people may become addicted to the NRT product and turn back to tobacco products to save money. Typically, the cost of NRT lasting seven days is up to £20 over the counter, whether spray, gum or inhaler, as against £4 to £6 for twenty tax paid cigarettes, or £3 for tax paid rolling tobacco. The cost of cigarettes or tobacco over the same period varies depending on the smoker, while the cost of NRT remains static regardless of the level of nicotine it contains. This leads to the relative cost of NRT versus cigarettes or tobacco being dependent on how much the individual smokes. The British NHS provides help in the form of prescriptions, reducing the cost to £7.40 per script or for free in Scotland, and if several products are included on one script then the price will drop well below that of actual cigarettes or may even cost nothing at all.
Evaluation of NRT in real-world studies produces much more modest outcomes than efficacy studies conducted by the industry-funded trials. The National Health Service (NHS) in England has a smoking cessation service based on pharmacotherapy in combination with counseling support. An ASH report claims that the average cost per life year gained for every smoker successfully treated by these services is less than £1,000, below the NICE guidelines of £20,000 per QALY (quality-adjusted life year). However, the investment in NHS stop smoking services is relatively low. A comparison with treatment costs for illicit drug users shows that £585 million is committed for 350,000 problem drug users compared to £56 million for 9 million users of tobacco. This is £6.20 for each smoker, compared to £1,670 per illegal drug user (Action on Smoking & Health, 2008).
Disappointingly, the claims for high efficacy and cost-effectiveness of NRT have not been substantiated in real-world effectiveness studies. Pierce and Gilpin (2002) stated their conclusion as follows: “Since becoming available over the counter, NRT appears no longer effective in increasing long-term successful cessation” (p. 1260). Efficacy studies, which are conducted using randomized controlled trials, do not transfer very well to real-world effectiveness. Bauld, Bell, McCullough, Richardson and Greaves (2009) reviewed 20 studies the effectiveness of intensive NHS treatments for smoking cessation published between 1990 and 2007. Quit rates showed a dramatic decrease between 4-weeks and one year. A quit rate of 53% at four weeks fell to only 15% at 1 year. Younger smokers, females, pregnant smokers and more deprived smokers had lower quit rates than other groups.
- Nicotine addiction
- Tobacco smoking
- Smoking cessation
- Tobacco cessation clinic
- American Legacy Foundation
- Stead et al. (2008), ch. 7
- Package insert monograph with Nicorette® inhaler
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