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 them 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 use of nicotine replacement therapy increases the success of initially quitting smoking by 50 to 70%. Patches may cause skin irritation. Safety with respect to heart attacks appears good.
It is on the World Health Organization's List of Essential Medicines, a list of the most important medication needed in a basic health system.
Gum, patches, nasal spray, inhaler and lozenges all improve the ability of people trying to quit smoking.
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 to the back of throat.
Electronic cigarettes are an emerging method for nicotine administration that consists of inhalation of a nicotine containing atomized solution. Electronic cigarettes offer users the option to wean themselves off nicotine by modifying the amount of nicotine they would normally get from smoking regularly to no nicotine at all. Negative health affects and efficacy are still under investigation and the Food and Drug Administration reflects this attitude.
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 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.
- Stead, LF; Perera, R; Bullen, C; Mant, D; Hartmann-Boyce, J; Cahill, K; Lancaster, T (Nov 14, 2012). Stead, Lindsay F, ed. "Nicotine replacement therapy for smoking cessation". The Cochrane database of systematic reviews 11: CD000146. doi:10.1002/14651858.CD000146.pub4. PMID 23152200.
- "WHO Model List of EssentialMedicines". World Health Organization. October 2013. Retrieved 22 April 2014.
- Package insert monograph with Nicorette® inhaler
- Phillips, CV; Heavner, KK (2009). "Smokeless tobacco: The epidemiology and politics of harm". Biomarkers 14 (Suppl 1): 79–84. doi:10.1080/13547500902965476. PMID 19604065.
- Doran et al. (2006), pp. 758–766
- Ferguson et al. (2006) in Addiction, pp. 59–69
- Pierce & Gilpin (2002) in JAMA v. 288 pp. 1260–1264
- Bauld et al. (2010) in J Public Health (Oxf), v. 32, pp. 71–82