Almost all researchers agree that nicotine is not a carcinogen and there is growing consensus that nicotine derived from medications does not promote cardiovascular disease. All of the NRT formulations are associated with slower onset and much lower nicotine levels than are cigarettes and of course they do not produce carbon monoxide, toxins, and carcinogens. The safety and abuse records of NRT have been excellent. The choice of NRT should be individualized – based on preference, past experience, smoking dependence and habits.
The labeling on NRT still instructs tobacco users to consult their clinician if there is a history of heart disease, ulcers, or hypertension or with pregnancy or breast feeding. But the only medical contraindications in the guideline are:
– Immediate myocardial infarction (< 2 weeks)
– Serious arrhythmia
– Serious or worsening angina pectoris
– Accelerated hypertension
There is a documented lack of an association between NRT and acute cardiovascular events in persons who continue to smoke while on the patch as well as in those who have had past cardiac events! The guideline recommends use of NRT in pregnancy if other therapies have failed. Clearly, the fetus is exposed to significantly less nicotine with NRT than with smoking and most importantly is not exposed to carbon monoxide, carcinogens and toxins from cigarettes.
Light smoking has become more common, perhaps due to smoking restrictions and increases in the price and taxation of tobacco products. Many light smokers have a strong dependence even though they smoke relatively few cigarettes. They are less likely to receive treatment than are heavier smokers but anecdotal evidence shows an increase in success rates for light smokers with use of NRT. At the other end of the spectrum, higher than recommended doses may be indicated in tobacco users with severe addiction. Failure to respond to NRT products may reflect inadequate dosage, incorrect usage, or both.
There are two non-nicotine medications available to tobacco users as well. Buproprion (Zyban), an atypical antidepressant, has been shown to double quit rates. It blocks the reuptake of dopamine and norepinephrine in the central nervous system which modulates the dopamine reward pathway and reduces cravings for nicotine and symptoms of withdrawal. It is effective in those whether or not this is current or past depressive symptoms. Combining bupropion with NRT often increases success rates over buproprion used alone.