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Am Fam Physician. 2000;61(5):1498-1500

Health professionals are likely to be asked by patients for assistance in initiating or maintaining smoking abstinence. Four nicotine replacement treatments (NRTs) are on the market: nicotine polacrilex (gum), the transdermal patch, a nasal spray and an inhaler. Each has been shown to improve a smoker's chance of achieving smoking cessation. However, there have been no direct comparisons among the different antismoking aids. Hajek and associates compared the four NRTs.

A total of 504 volunteers who were smoking 10 or more cigarettes per day and seeking assistance to stop smoking was evaluated. The subjects were asked to complete a questionnaire before attending the first session, where they were asked to stop smoking. At this session, all subjects watched a video on the four products and were asked their opinion of the products. They were then randomized to receive one of the products: nicotine polacrilex, in a dosage of 2 or 4 mg (10 to 12 pieces) per day; the nicotine transdermal patch, in a dosage of one patch per day; nicotine nasal spray, in a dosage of 30 inhalations per day; and a nicotine inhaler, in a dosage of six cartridges per day. The NRTs were administered for a 12-week period. The subjects paid for their NRTs.

Results demonstrated that compliance was high for the patch and low for the other products. Only 17 to 48 percent of abstaining subjects in the first week used the recommended amount of NRTs. Subjects using the spray and inhaler complied with the recommended use less often than subjects using the gum did. All three of these groups had lower compliance than the group using the patch. The patch was rated as easier to use than the other NRTs during the first week.

The most common reason for not using the patch was forgetting to put it on, while for the other NRTs, the reason was a belief that the subjects did not need the aid. Adverse effects were cited more often as a reason for nonuse with the spray than with the other products. Other reasons for nonuse included embarrassment, being ill and avoiding dependence. The inhaler was most often cited as being embarrassing to use.

Subjects using the spray had lower saliva cotinine levels after one week of abstinence than those using the gum. Those using the inhaler had higher cotinine concentrations than those using the patch. The NRTs did not differ significantly with regard to effects on withdrawal symptoms, difficulty in not smoking, urges to smoke at week 1 or weight gain at week 12. The NRTs did not differ for abstinence rates. The relapse rates of nonsmoking subjects who used the products were compared with those of subjects who failed to use NRT during the first week of abstinence. There were no differences among the subjects using gum, patch or inhaler. However, the subjects using the nasal spray at week 1 did significantly better at week 12 in terms of sustained abstinence. The level of initial use was positively related to subsequent abstinence.

The authors conclude that nicotine nasal spray, which has the fastest nicotine delivery, may be more helpful to those who use it properly, but it causes more adverse effects and tends to be underused. The inhaler was more embarrassing to subjects. All of the NRTs have similar perceived helpfulness and similar effects on craving, withdrawal symptoms and abstinence success.

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