What is Nicotine Replacement Therapy?

Nicotine is a highly addictive substance. Because it changes your brain chemistry, you will probably experience cravings and withdrawal symptoms when you quit smoking. Nicotine replacement therapies (NRTs) are very effective over-the-counter and prescription medications that can help you overcome nicotine addiction without the harmful chemicals in cigarettes.

In 2015, according to data collected by the Centers for Disease Control and Prevention, over two-thirds of adult smokers wanted to quit. Over half had attempted to quit smoking in the previous year, but fewer than 10% actually succeeded in quitting.¹  NRT can reduce cravings and withdrawal symptoms and increase the likelihood of successfully quitting smoking by delivering controlled doses of nicotine to your brain.

Understanding Nicotine Replacement Therapy (NRT)

Nicotine replacement therapies (NRTs) deliver a small, controlled dose of nicotine to the brain without all the harmful chemicals found in cigarette smoke. NRTs are available in short-acting and long-acting formulas and several preparations, including lozenges, gums, inhalers, and nasal sprays.

Typically, the most effective way to use NRTs is to combine a long-acting nicotine patch with a short-acting product and plan to extend treatment over 12 weeks.² Over time, the dose of NRT is slowly lowered as your brain adapts. Eventually, you will be completely nicotine-free.

How Does Nicotine Replacement Therapy Help Quit Smoking?

Nicotine quickly enters your bloodstream and binds to receptors in your brain. After binding to its receptors, nicotine causes many other brain chemicals to be released, having an effect throughout the body. Because nicotine causes changes in brain chemistry, it also leads to tolerance. Your brain needs a higher and higher dose to get the same effects.

Nicotine replacement therapies mitigate nicotine withdrawal symptoms. They have several potential benefits, including:

• Reducing cravings for cigarettes
• Easing withdrawal symptoms such as irritability and anxiety
• Improving the chances of successfully quitting smoking

Types of Nicotine Replacement Therapy

Seven U.S. Food and Drug Administration (FDA)-approved medications are available for smoking cessation. Five of these medications are NRTs. The U.S. Agency for Healthcare Research and Quality advises that nicotine replacement therapy (NRT) is safe for all adults who want to quit smoking, except pregnant women and teens. People with a history of heart disease or who plan to continue to smoke while taking NRTs should talk to their doctor.

Bupropion and varenicline are two prescription medications that also help smokers overcome nicotine addiction but are not NRTs. Smokers who use these medications or nicotine-replacement therapies double their chances of success.³

Nicotine Patches

Nicotine patches are applied to the skin, where they deliver low doses of nicotine throughout the day. You apply a patch and leave it in place all day. It can be hidden under clothing and left in place while you shower.

Remove the patch from the foil packaging. Peel off the protective strips. Apply the patch to your skin and smooth it to ensure it sticks.

Nicotine patches are available over the counter and come in 7 mg, 14 mg, and 21 mg strengths. Your doctor will probably recommend the higher-dose patch if you smoke over ten cigarettes in a day. Over the next 8 to 12 weeks, lower your dose with the goal of discontinuing use.

Don’t wear more than one patch at a time. To minimize skin irritation, apply the patch daily to a different, clean, dry, hair-free area on the upper body.

Nicotine Gum and Lozenges

Nicotine gum and lozenges deliver nicotine through the lining of your mouth. These medications are available over the counter, and their effects last for one to two hours.

Nicotine gum

Chew nicotine gum slowly until you get a tingling sensation, then tuck the gum between your cheek and gum until the taste fades. Repeat this process. Chew the gum until the taste returns, and then hold it between your cheek and gum until the taste fades. Repeat for 20 to 30 minutes.

Don’t use more than 24 pieces of gum in 24 hours.

Nicotine lozenge

Put the nicotine lozenge between your cheek and gum for 20 to 30 minutes, or until it is fully dissolved. Move the lozenge from side to side in your mouth. Do not bite or swallow the lozenge.

Don’t use more than five lozenges in any 5 hours or more than 20 lozenges per day. Reduce the number of lozenges used over the next six weeks. Do not take more than one lozenge at a time, or use them back-to-back.

Refrain from eating or drinking while using nicotine gum or lozenges or for 15 minutes before using them. Drinking acidic beverages, such as coffee and carbonated drinks, can reduce nicotine absorption.

Nicotine gum and nicotine lozenges come in 2 mg and 4 mg strengths. Typically, your doctor will recommend the higher dose if you have your first cigarette within 30 minutes of awakening.

Talk to your doctor about how many pieces of gum or lozenges you should use each day and how long you should plan to continue using them.

Nicotine Nasal Spray and Inhaler

Nicotine oral inhalers and nasal sprays are only available by prescription.

Nicotine nasal spray

To use NRT nasal sprays, blow your nose to clear any mucus. Insert the tip of the bottle into your nostril. As you breathe through your mouth, deliver one spray of the medication into each nostril. Do not sniff, swallow, or inhale while spraying. If your nose runs, sniff gently to keep the medication in your nose.

Nicotine inhaler

An NRT inhaler is designed like a cigarette. Use the inhaler for four 5-minute sessions, or about 20 minutes, taking frequent short, shallow puffs. Most nicotine from the NRT inhaler will be absorbed in the back of the throat, not the lungs.

Refrain from eating or drinking while using nicotine inhalers or for 15 minutes before using them.

Your prescription should note how many sprays or inhalations you should use daily. Ask your doctor for a typical schedule and length of treatment.

NRT products deliver a low dose of nicotine to take the edge off nicotine withdrawal symptoms. You may still experience some cravings and withdrawal symptoms. If so, consult with a TelegraMD doctor on call. Medical professionals are available 24 hours a day to review your symptoms and prescribe the most effective NRT to treat them. Telemedicine appointments for NRT are typically much more cost-effective than in-person appointments.

Choosing the Best Nicotine Replacement Therapy

Talk to your doctor to determine the most suitable NRT product for you. It will depend on your preferences and how many cigarettes you smoke daily. There are many combinations, both over-the-counter and available through an online prescription.

Taking NRT for a sufficient duration and at a high enough dose is crucial to enabling your brain to gradually adjust to reduced nicotine levels and to relieve your withdrawal symptoms and cravings.

Potential Side Effects of Nicotine Replacement Therapy

Unlike cigarette smoking, NRTs will not increase your risk for cancer, lung disease, or heart disease. However, you may experience some side effects when using these products, including:

• Mild skin irritation or rash when using the skin patch
• Upset stomach when using NRT gum or lozenge
• Headache if the nicotine dose is too high
• Sleep disturbances if a nicotine patch is worn at night
• Dizziness
• Racing heartbeat if the nicotine dose is too high
• Muscle aches or stiffness
• Sore throat and mouth irritation
• Jaw discomfort
• Nasal irritation from NRT nasal sprays

Psychological Effects of Quitting Smoking

Cravings, irritability, and withdrawal symptoms make it difficult to stop smoking.

A craving is a strong, distracting urge to smoke. Cravings are most intense right after you quit smoking. Plan for them by developing a list of activities that can distract you from your cravings. Learn meditation and deep breathing techniques to reduce stress.

Withdrawal symptoms can cause insomnia, mood changes, cravings, anxiety, restlessness, and depression. Difficulty sleeping can make psychological symptoms associated with quitting smoking feel worse and more difficult to manage.  

While the psychological effects of quitting smoking can feel like a huge barrier to overcome, researchers have found that smoking cessation for at least 15 weeks was associated with significant improvements in mental health symptoms, as evidenced by trial enrollee’s depression and anxiety scores.⁴

Safety Precautions and Considerations

Nicotine replacement therapies deliver nicotine, which can be dangerous if the dose is too high. Use only the recommended dose. Keep all NRT products out of the reach of children and pets.

Fold NRT patches so the medicated side is in. Wrap gum and lozenges in paper and throw them away. Take extra care to dispose of NRT inhalers and nasal sprays so children and pets cannot access them. Used cartridges and spray bottles still contain enough nicotine to cause harm.

How To Prevent a Relapse

Congratulations on having a quit-smoking plan in place and taking the step to stop smoking. It took a lot of hard work to get to this point. The last thing you want to happen is a relapse.

To prevent a smoking relapse, try some of these strategies:

• Throw away all of your smoking paraphernalia.
• Lean on your friends and family for support when you feel the urge to smoke again.
• Consider joining an online or in-person support group or a more formal smoking cessation program.
• Contact a medical professional on the TelegraMD platform for support, whether for prescription smoking cessation medications or psychological support. When combined with medication, cognitive-behavioral therapies increase your chances of successfully quitting smoking, compared to support alone.⁵
• Identify your triggers and change your schedule and environment so you can avoid them.  
• Use quitlines: These telephone-based resources are available in every U.S. state. Call 1-800-QUIT-NOW or 1-800-784-8669.
• Get Text messaging support: Text QUITNOW to 333888 for free help in English and Spanish.
• Use smartphone apps such as The National Cancer Institute’s quitSTART app.

Disclaimer

While we strive to always provide accurate, current, and safe advice in all of our articles and guides, it’s important to stress that they are no substitute for medical advice from a doctor or healthcare provider. You should always consult a practicing professional who can diagnose your specific case. The content we’ve included in this guide is merely meant to be informational and does not constitute medical advice.

References

1. Centers for Disease Control and Prevention. Smoking cessation: fast facts.
2. Fiore MC, Jaen CR, Baker TB, et al. Clinical Practice Guideline. Rockville, MD: U.S. Department of Health and Human Services. Public Health Service; 2008. May, Treating Tobacco Use and Dependence: 2008 Update.
3. Rigotti NA. Strategies to Help a Smoker Who Is Struggling to Quit. JAMA. 2012;308(15):1573–1580. doi:10.1001/jama.2012.13043
4. Wu AD, Gao M, Aveyard P, Taylor G. Smoking Cessation and Changes in Anxiety and Depression in Adults With and Without Psychiatric Disorders. JAMA Netw Open. 2023;6(5):e2316111. doi:10.1001/jamanetworkopen.2023.16111
5. Stead LF, Koilpillai P, Fanshawe TR, Lancaster T. Combined pharmacotherapy and behavioural interventions for smoking cessation. Cochrane Database Syst Rev. 2016 Mar 24;3(3):CD008286. doi: 10.1002/14651858.CD008286.pub3. PMID: 27009521; PMCID: PMC10042551

Additional References

Centers for Disease Control and Prevention. (2021). How to use nicotine gum.

Centers for Disease Control and Prevention. (2021). How to use nicotine lozenges.

Centers for Disease Control and Prevention. (2021). How to use the nicotine nasal spray.

Centers for Disease Control and Prevention. (2021). How to use the nicotine oral inhaler.

Centers for Disease Control and Prevention. (2021). Nicotine gum.

Centers for Disease Control and Prevention. (2021). Nicotine lozenge.

Centers for Disease Control and Prevention. (2021). Nicotine nasal spray.

Centers for Disease Control and Prevention. (2021). Nicotine oral inhaler.

Centers for Disease Control and Prevention. (2021). Nicotine patch.