What are the recommended treatments for tobacco abuse, including nicotine replacement therapy (NRT) options?

Nicotine Gum for Tobacco Cessation

Nicotine gum is an effective FDA-approved nicotine replacement therapy (NRT) that should be used as part of combination therapy with a nicotine patch, not as monotherapy, to maximize smoking cessation success. 1, 2

First-Line Treatment Approach

Combination NRT (patch + gum) is the recommended first-line approach, achieving 36.5% abstinence at 6 months compared to 23.4% for patch alone—nearly doubling cessation success rates (OR 3.6,95% CI 2.5-5.2). 1, 2

Nicotine Gum Dosing

• For smokers consuming ≥10 cigarettes per day: Use 4 mg nicotine gum combined with a 21 mg/24-hour nicotine patch. 2
• For lighter smokers (<10 cigarettes per day): Use 2 mg nicotine gum combined with a 14-15 mg nicotine patch. 2
• Frequency: Use 8-12 pieces of gum per day as needed for cravings. 2

Proper Administration Technique

• Chew slowly to allow nicotine absorption through the oral mucosa—do not swallow the nicotine. 2
• Use "chew and park" technique: chew until peppery taste emerges, then park between cheek and gum to allow absorption. 1
• Avoid eating or drinking 15 minutes before and during gum use, as acidic beverages can reduce nicotine absorption. 1

Treatment Duration

• Minimum 12 weeks of combination NRT for the initial quit attempt. 2, 3
• Longer duration (>14 weeks) shows superior results to standard 8-12 week courses. 1, 2
• Therapy may be extended up to 6-12 months to promote continued cessation. 2, 3

Common Adverse Effects

• Jaw fatigue and soreness, hiccupping, burping, and nausea are the most common side effects specific to nicotine gum. 1
• These effects are typically mild and manageable, rarely requiring discontinuation. 1

Critical Success Factors

Behavioral counseling must be combined with pharmacotherapy—this combination increases quit rates from 8.6% to 15.2% compared to brief advice alone. 4, 5

• Provide at least 4 counseling sessions during each 12-week course of pharmacotherapy. 6
• Include practical skills training, social support, and motivational interviewing. 6
• Schedule follow-up within 2 weeks after starting treatment, then at minimum 12-week intervals. 2, 3

Alternative Pharmacotherapy Options

If combination NRT fails or is contraindicated:

• Varenicline (1 mg twice daily for 12 weeks) achieves the highest single-agent quit rate at 33.2% (OR 3.1 vs placebo, 95% CI 2.5-3.8). 1, 7
• Bupropion SR (150 mg twice daily) achieves 24.2% abstinence (OR 2.0 vs placebo). 1
• Varenicline is superior to bupropion and NRT monotherapy based on the EAGLES trial (21.8% vs 16.2% vs 15.7% respectively at 6 months). 7, 4

Safety Considerations

• NRT is safe even in patients with cardiovascular disease—blood nicotine levels from NRT remain significantly lower than from smoking cigarettes. 1, 2
• The risk of developing dependence on NRT products is very low. 1, 2
• For pregnant smokers, consultation with an obstetrician is recommended, though benefits of NRT likely outweigh risks of continued smoking. 2, 6

Common Pitfalls to Avoid

• Inadequate dosing: Ensure patients use sufficient nicotine doses (4 mg gum for heavier smokers) to control withdrawal symptoms. 2
• Monotherapy instead of combination: Single-agent NRT is substantially less effective than combination therapy. 1, 2
• Premature discontinuation: Encourage continued therapy even through brief slips—tobacco dependence is a chronic condition requiring repeated intervention. 2, 8
• Insufficient treatment duration: Maintain treatment for at least 12 weeks, with consideration for extension to 6-12 months. 2, 3
• Lack of behavioral support: Pharmacotherapy alone is less effective; always combine with counseling. 4, 5